NSA I-Tact
If you are joining/unjoining a community, please email info@edpma.org so we can forward Outlook... View more
Aetna, Cigna Didn’t Disclose Key Surprise Billing Data, CMS Says
-
Aetna, Cigna Didn’t Disclose Key Surprise Billing Data, CMS Says
Aetna, Cigna Didn’t Disclose Key Surprise Billing Data, CMS Says
o Audits focused on key payment metric used in negotiations
o Insurers also missed deadlines to pay or deny medical claims
By Lauren Clason / September 5, 2024 02:24PM ET / Bloomberg Law
Four Aetna Inc. and Cigna Healthcare plans in Florida and Tennessee failed to report a key payment metric to medical providers in hundreds of cases, according to reports released by the Biden administration Thursday.
The No Surprises Act required insurance companies and health care providers to settle certain emergency out-of-network billing disputes themselves, shielding patients from unexpected high costs. When responding to provider invoices, insurers must also disclose the median in-network rate for the services, also known as the qualifying payment amount.
The reports of missing QPAs underscore provider complaints that insurance companies aren’t following the rules created by the surprise billing law.
Providers are repeatedly suing insurance companies over what they allege are deceptions around the QPA, which is often a central factor in settling billing disputes. The Fifth Circuit heard oral arguments Tuesday in an appeal from the Department of Health and Human Services that partly focused on how the QPA is calculated, while an earlier loss forced HHS to revise guidance that instructed arbitrators to consider the QPA as a “primary” factor in decisions.
The Centers for Medicare and Medicaid Services posted four reports outlining deficiencies in the Aetna and Cigna plans’ disclosures to doctors over the 2022 calendar year. CMS identified 151 instances of Aetna not disclosing the QPA for services under the School Board of Broward County Employee Health Plan in Florida, and 370 incidents in Florida’s State Group Insurance Health Plan.
CMS previously found that Aetna had miscalculated the QPA in a handful of cases.
The audit likewise found 178 violations around Cigna’s QPA disclosures under the Tennessee State Group Insurance Program and 103 incidents under the Metropolitan Nashville Public Schools Group Health Plan for Certificated Employee & Retirees.
The Cigna plans additionally failed to either pay or deny bills within a 30-day deadline in a number of cases, the audit found, which is necessary before the parties can proceed to arbitration.
Aetna and Cigna did not immediately respond to a request for comment.
To contact the reporter on this story: Lauren Clason in Washington at lclason@bloombergindustry.com
To contact the editor responsible for this story: Alex Ruoff at aruoff@bloombergindustry.com
-
0 Replies
Sorry, there were no replies found.
Log in to reply.