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Draft of EDPMA Out of State Medicaid Reciprocity Statement
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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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Here are a few takeaways:
Increased use of IDR – but fewer ineligible disputes:
- “During the
first half of 2023, IDR entities closed 134,036 disputes, 124,827 of which
were for OON emergency/nonemergency services[.]” (The rest was for OON air
ambulance.) This total is more than 2x the total number of disputes closed
in 2022, which was 54,821. - However, “The
percentage of disputes found to be ineligible in the first half of 2023
was substantially less than the percentage of ineligible disputes in 2022
(22% in Q1 and Q2 of 2023 versus 45% in 2022).”
Insurers’ use of QPA:
- “Researchers
found that when
insurers were the prevailing party in Q2 of 2023, the median payment
determination was 100% of QPA. In contrast, when providers were the
prevailing party in Q2 of 2023, the median payment determination was 322%
of the QPA[.]”
Providers continue to prevail in disputes by an overwhelming margin:
- Providers and
facilities were the prevailing party in approximately 77% of OON
emergency/nonemergency service and OON air ambulance service
determinations during the first half of 2023.
Top initiating parties and private equity link:
- Top initiating
parties: Team Health was number 1 in both Q1 and Q2, SCP was second in
both quarters, and Envision and Radiology Partners traded third and fourth
place between Q1 and Q2. - Team
Health and SCP together account for over 50% of the disputes in Q1 and Q2. - CRS draws the link to private equity:
“Provider entities with evidence of private equity affiliations comprised
5 of the top 10 initiating entities and initiated over 70% of all
disputes[.]”
A single insurer was involved in over 35% of all disputes:
- “Among
non-initiating parties for OON emergency/nonemergency service disputes, UnitedHealthcare was the
most common non-initiating party, constituting over 35% of all disputes in
both Q1 and Q2 of 2023. - I did not
include the air ambulance data in this overview, but given the recent
attention on Multiplan, I am including this tidbit: “Among non-initiating
parties for OON air ambulance service disputes, Multiplan was the only
non-initiating party to be involved in at least 10% of disputes in either
Q1 or Q2.”
Timeline for payment determinations:
- CRS notes the
majority of determinations were made outside of the 33-day window (up to 3
business days for the IDRE to determine eligibility and up to 30 business
days to make the payment determination). In fact, the median number of
days to payment determination increased for OON emergency/nonemergency
service disputes from 52 business days in Q1 to 71 business days in Q2[.]” - However,
the percentage of disputes resolved within the timeline increased
in Q2 versus Q1, which may indicate improvement. - CRS
also notes that the data does not explain why the timeline was not met for
disputes so this does not necessarily indicate poor performance by IDREs,
since there are legitimate reasons (e.g., extensions) that a dispute may
take longer than 33 days. Thus, it is difficult to draw precise
conclusions about why this is happening. - Note: CRS
provides some granular data here. They break out the median number of
business days for a determination by: quarter, whether a state has a
bifurcated system, and dispute type (batched, bundled, or single). (Table
1, p. 8)
Concentration in five states:
- In both Q1 and
Q2, over half of all disputes involving OON emergency/nonemergency
services were initiated in the same five states: Arizona, Florida,
Georgia, Tennessee, and Texas. - CRS adds: “Of
these five states, three (Florida, Georgia, and Texas) are commonly
referred to as bifurcated states, meaning states in which some OON
emergency/nonemergency services are subject to the federal IDR process and
others are subject to a specified state law or all-payer model agreement.”
- “During the
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Sorry for the delay @jennifer-brownpephealth-net – I was in DC for the ACEP Leadership and Advocacy Conference.
See update from Bob Jasak:
Q: “Are they acknowledging that we can’t initiate ON without the 835, but doing nothing about that reality?”
A: As of Friday, yes. I expressly said to them it would be impossible to initiate Open Negotiation because you wouldn’t know what the money deposited in the bank account was for. They seem to be fully aware of what I’m saying and acknowledging that they are not yet prepared to do anything about. But they said they are still trying to figure out what they can do.
If anyone has received a “delayed” 835 (For example, let’s say funds were deposited on March 1st and the corresponding 835 came in today), it would be helpful if you could share with me what you receive. I was asking them how they would even kick something out if you started just operating on the date you received the 835 and seeing what they would say. They didn’t know how to answer. So in particular, I’d be interested on every date that is on that document and whether it reflects the actual receipt or is some date that is stale because of the delay.
I discussed Bob’s ask with Jen yesterday. Her group has not received any 835s yet.We have asked the Hart Health team to recommend strategies and tactics if the system does not open next week. So stay tuned.
Jen also said that the Change is supposed to be fully operational the week of April 22.
Time will tell…….
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Welcome Codie!
This working group meets when there is an issue where EDPMA may respond. They help determine if a response is needed and if so, recommend the messaging in the response.
You can also post your response in the QCDC Committee channel for a broader audience.
We are thrilled you are jumping in!
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Dr. Murphy’s staffer said he put both questions that we and ACEP shared with him in Dr. Murphy’s binder for the hearing tomorrow. Not a guarantee, but a promising sign nonetheless.
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While this is good news for practices that have been negatively impacted by the cyberattack, it also could result in a smaller pool of funding to reward those with high performance due to the budget neutral nature of MIPS.
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👍
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Hey Quality Measures Subcommittee!
How would you like to review and recommend comments to the E&M Guidebook?
Perhaps review and add comments here and then a possible meeting to confer?
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- Every year, the PQM will randomly assign E&M Project Committee members to the Advisory Group or Recommendations Group.
- Appointments will generally be for 3 years, but for the very first term (Fall 2023 Cycle), they will stagger terms- some will get 1, 2, or 2 year terms, but after that everyone will be appointed for 3 years.
- For E&M Committee, only individuals can submit a nomination, not organizations. For PRMR (formerly MAP process) and MSR (measure removal process), organizational nominations will be permitted.
- To nominate, you must be PQM member, but membership is free and encouraged (see: https://www.p4qm.org/)
- Here’s a visual of the E&M Committee process:
- There will also be opportunities for ad hoc, off-cycle reviews (e.g., if there’s an update to a measure or something that draws attention to unintended consequences)
- PQM is currently completing the two active cycles, Fall 2022 and Spring 2023, using the NQF process and committee structure. The next cycle, which will adhere to the new process, is Fall 2023.
- As noted above, the PQM announced its first Call for Nominations for PQM Committees today (deadline is July 30). Once selected, rosters will be open for public comment.
Here is a more specific overview of the E&M Process:
- Intent to submit measure: available in October 1st and April 1st: submit basic measure info to prepare PQM for proper review
- Full measure submission a month later: Nov 1 and May 1. Submit through PQM STAR system.
- Internal measure review/staff assessment. Bring forward issues that standing committees should be aware of. 5 domains: importance, feasibility, scientific acceptability (reliability and validity), equity, and use/usability. This process takes 4-5 weeks. Assessment shared with developers and stewards for factual review before they go to committees.
- Public Comment Period: 30 days, starts once measure is submitted. Full record of public comments will be available on PQM website. PQM will also provide a summary of these comments
- Endorsement Committee Review: independent review of measures. Will look at staff preliminary recommendations and PQM measure evaluation Rubric to see if consensus is lacking anywhere. This will take 3 weeks.
- E&M Committee Review and Endorsement: E/M Committee meets to review measures that lack consensus, based on aggregated independent committee-member reviews. Vote is only on the endorsement decision, not all the domains used to assess measure. Just non-consensus.
- How do they determine consensus? Consensus is determined to be 75% or higher agreement among members (presented evidence to support this level). Under NQF it was greater than 66%
- This takes place in Jan/Feb (Fall) or July/August (Spring)
- Decision Outcomes. Endorsed, endorsed with conditions, not endorsed or endorsement removed.
- Appeals Period:
- 3 weeks.
- Just submitting an appeal doesn’t mean an appeals committee will be convened. There are criteria that must be met (reviewed by E&M Team). If eligible, ad hoc committee is convened (committees consists of all co-chairs from across the E&M Committees plus Battelle staff and any subject experts needed). Can submit an appeal for measure that was endorsed or not endorsed (under NQF was just the former).
i. If measure was endorsed, appeal must cite evidence that the appellant’s interests are directly and materially affected by the measure and that the CBE’s endorsement of measure has had, or will have, an adverse effect on those interests; AND cite existence of a CBE procedural error or information that was available by Intent ot Submit deadline but was not considered by E&M Committee.
ii. If measure was not endorsed, appeal must be based on 1) the CBE’s measure evaluation criteria were not applied appropriately; or 2) CBE’s E&M process was not followed. Appellant must specify how these items were not fulfilled
- Feb/March (Fall) and Aug/Sept (Spring)
- Importantly, PQM noted that there will be no changes to the measure endorsement criteria at this time, just the forms themselves.
Q/A
- Will PQM preserve the current NQF Scientific Methods Committee. The PQM has done outreach to NQF Scientific Methods Committee and will try to maintain as many of them as possible.
- How to identify ad hoc experts? May look to other existing committees and then to PQM members.
- Measure developers role in process: developers will be aware of any public comments (publicly posted) and committee concerns. Developers have opportunity to do a factual review of the staff assessments before they go to committee for independent review (formerly, “preliminary analyses”). After they got to committee and if there’s not consensus, developers will have access to that information (and they can attend meeting and provide overview of the measure). Developers (and any stakeholder) can also submit an appeal. PQM will also be working with developers on “readiness” for each cycle and if it’s not ready for current cycle, how to ready it for next cycle (particularly for first Fall 2023 cycle). Battelle will reach out to developers who have measures up for maintenance in Fall 2023 (as well as new developers). There will also be a webinar in the fall regarding the submission of measures.
- PQM fully recognizes that they will need to pull in additional expertise in addition to the members of the broader 5 E&M Committees. They would do this after the developer’s intent to submit deadline.
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👍 will do!
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I’m tagging @jthroopecs-wmi-com
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Great connection @alan-eismand2ihc-com .
Would the group like to meet to explore and develop EDPMA’s strategy?