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CMS Posts First QPA Audit Report
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CMS Posts First QPA Audit Report
From Bob Jasak:
Link to the report here: https://www.cms.gov/files/document/qpa-final-report-aetna-tx.pdf
Looks like it’s only Air Ambulance related (and is limited to Aetna Texas: “Aetna Health Inc., of Texas, (Aetna) is an insurance company licensed by the Texas Department of Insurance to sell health insurance in Texas and is subject to regulation by the State of Texas as well as CCIIO. Aetna offers a range of insurance and employee benefit products, as well as related programs and services.”)
But FYI:
- Finding 1 – Failing to
properly calculate the QPA by using claim paid amounts instead of
contracted rates, and counting each claim as its own contracted rate, even
when the claims were for the same amounts for the same item or service and
to the same provider of air ambulance services. - Finding 2 – Failing to
provide a statement that, generally, the provider may initiate the IDR
process within four (4) days after the end of the open negotiation period - Finding 3 – Failing to
provide the QPA with an initial payment or notice of denial of payment.
- Observation 1 – Failing
to calculate the QPA in accordance with then-applicable rules by excluding
contracted rates for contracts under which no claims were filed.
- Finding 1 – Failing to
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1 Reply
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From Bloomberg Government
CMS Audit Faults Aetna for Errors in Surprise Billing Payments
o Aetna addressed all errors identified in the report
o Audit is the first since passage of the No Surprises Act
By Lauren Clason / July 11, 2024 05:10PM ET / Bloomberg Law
Aetna Health Inc. did not properly calculate benchmarks in some negotiations with providers over surprise medical bills, according to a new federal audit.
The Centers for Medicare and Medicaid Services released its first compliance audit under the No Surprises Act on Thursday, finding that Aetna did not follow proper procedure in a handful of cases involving payments for air ambulance services between January and June 2022.
The report provides more ammunition to medical providers in their arguments that insurers are gaming the system. Doctors are increasingly suing insurance companies in court over allegedly delayed or missing payments, skewed arbitrator selections, and miscalculated benchmarks.
The No Surprises Act shields patients from unexpected out-of-network bills in emergency situations, or bills from out-of-network providers at in-network facilities. Insurers and providers are now required to resolve the billing disputes between themselves.
The audit found that in five disputes with air ambulance providers, Aetna incorrectly included the amount it actually paid for claims rather than the contracted rate in determining the qualified payment amount, or median in-network rate. The QPA is a key factor that arbitrators are required to consider in resolving disputes, and is the subject of ongoing litigation. CMS previously had to revise its calculation guidance following a court loss in 2023.
“This routine audit took place during the first six months of 2022, following the initial implementation of the requirements,” Aetna said in a statement. “We addressed all the report’s findings to CMS’ satisfaction.”
The audit also identified several other deficiencies. Aetna improperly excluded contract rates from the QPA five times for contracts that had filed no relevant claims, contrary to a rule that was in place at the time.
In one instance, Aetna did not alert a provider about the ability to initiate the arbitration process within the allotted four-day timeframe. In another, the insurer did not properly share the QPA.
To contact the reporter on this story: Lauren Clason in Washington at lclason@bloombergindustry.com
To contact the editor responsible for this story: Rebekah Mintzer at rmintzer@bloombergindustry.com
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