Two years into the No Surprises Act: Are you compliant with federal regulations?

In response to the Qualifying Payment Amount rules, many organizations have turned to MarketScan data to achieve and maintain cost-sharing compliance.

The No Surprises Act (NSA) went into effect on January 1, 2022 to protect patients against surprise billing for out-of-network emergency services and services rendered by an out-of-network provider in an in-network facility.

We continue to hear about the challenges with achieving and maintaining compliance with regulations outlined by the No Surprises Act, specifically in determining the Qualifying Payment Amount (QPA) for a service where no median contracted rate is available. This becomes more challenging for services rendered outside the network entirely, which can vary widely across the more than 3,000 geographic markets in the US. To comply with the new regulations, health plans are required to rely on eligible third-party databases, as defined by law.

The MarketScan® Reimbursement Benchmarks for Qualifying Payment Amount (QPA) accelerates compliance by offering a robust benchmark methodology to determine a the cost-sharing basis for services and items included in the balance-billing protections in the NSA.

Simplifying and accelerating QPA determination: A MarketScan client success story

In October of 2021, a large health plan client started sharing concerns with Merative about how they were going to comply with the upcoming mandates. They understood how to develop their own QPAs using contracted rates, but were anxious to line up an eligible third-party database before the mandate went into effect. With the unpredictability of when or where a member might experience an emergency, health plans are left with a narrow window for identifying and offering a QPA to the servicing provider. After learning about the depth and breadth of the Reimbursement Benchmarks for QPA solution, one large health plan partnered with Merative and was able to bring the full dataset in house before the end of the year.

Reimbursement Benchmarks for QPA are designed with the understanding that clients are not able to work with a vendor in real-time to determine a QPA on a case-by-case basis. Therefore, our solution consists of datasets that are easily ingestible into any system, allowing ease of access to the needed QPA.

The month after ingesting the Reimbursement Benchmarks for QPA data files, the health plan faced their first instance in which an eligible database was needed to determine QPAs. One of their members traveled to a state outside their network and received emergency services covered by the surprise billing protections of the No Surprises Act. The health plan was able to use Reimbursement Benchmarks for QPA quickly and efficiently, lining up the servicing market, site of service, CPT/HCPCS – Modifier combination, and provider specialty and land on the appropriate QPAs for services rendered. Confidence that the data they relied on was a fair representation of in-network rates for that specific market and set of services enabled the health plan to act quickly and decisively to remain compliant and navigate the new mandates with ease. They remain a partner of Merative’s to this day.

How MarketScan informed CMS in developing the methodology for QPA

When the Consolidated Appropriations Act of 2021 (CAA) was signed into law on December 27, 2020, it contained an important provision under the No Surprises Act to protect healthcare consumers against surprise bills and take them out of the middle of any payer-provider contention regarding payment for services rendered.

Sec. 102. Health Insurance Requirements Regarding Surprise Medical Billing ensures when members are provided emergency services out of their network or receive services from non-participating providers at in-network facilities, they are afforded financial protections. This includes that a member’s out-of-pocket expenses are no greater than they would be if the services were rendered by participating providers. In cases where an out-of-network provider’s charges are lower than in-network rates this is solved. More frequently, out-of-network provider’s rates are higher than network providers, and a Qualifying Payment Amount is then used to determine the recognized amount and basis for the member’s out of pocket expense. Sec 102 introduced the concept of the QPA, requiring the Departments to issue rulemaking on an accelerated timeframe (six months) that would establish the methodology to be used to determine the QPA. Additionally, this rulemaking would clarify what databases would be eligible for determining a QPA when a payer had insufficient information.

The Centers for Medicare & Medicaid Services (CMS) needed to move fast, and in March, CMS’s Center for Consumer Information and Insurance Oversight (CCIIO) turned to Merative. They were seeking information and data-driven insights to help inform their methodology. Using the MarketScan Commercial database, the Merative team quickly developed a whitepaper to assist them in developing the QPA methodology.

The Merative team determined that the long-standing Reimbursement Benchmarks solution, an offering that has been available since 2007 and built on the MarketScan database, would meet the requirements of a third-party eligible database. Payers can rely on an eligible database to determine median in-network allowed amounts for a market when they do not have direct contracted rates for the specific services their members received which were covered under the financial protections of the No Surprises Act. The Reimbursement Benchmarks solution has consistently received strong market acceptance for the accuracy and wide representation of the data included. Because of this strong base Merative was able to rapidly refine the offering to specifically offer median allowed amounts in the commercial market, creating tailored Reimbursement Benchmarks for QPA. Covering every geographic region and market nationwide to the specifications outlined in the rule, Reimbursement Benchmarks for QPA facilitates the identification of a QPA when a payer lacks sufficient information to determine their own QPA.

For over 40 years, our organization has worked with clients across the healthcare ecosystem on today’s most pressing challenges, turning data into trusted, actionable insights.

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