1/ CMS has done exactly what Congress refused to do--Congress rejected several "benchmarking bills" (setting physician reimbursement at a determined std.) in 2019 for out of network (OON)/balance billing (BB) & passed the #NSA which expressly avoided "rate setting", now in .....
2/ federal rule making @CMSGov has said that the "qualifying payment amount" (QPA) (median in network rate for same/similar services for same specialty in an MSA as of 1/31/2019) is the "presump[tive] appropriate OON amount"--not 1 of several factors to be used as Congress said..
3/ physicians may bring in other factors (thx CMS, Congress specified that they could in statute) if the information is "credible" + the physician must "clearly demonstrate" that the value of the service is materially different from the QPA & that the adjudicator "must consider".
4/ the physician's information. So CMS took a statute that listed several factors (not weighting any factor more than the other)--qualifications of the physician + complexity of the case + prior contract rates for 4 years + market concentration + quality & outcomes--& made it ..
5/ into a benchmarking law which Congress rejected in 2019 in the E&C bill and the Pallone/Alexander compromise--time for Congress to tell CMS that was not their express intent. @amychomd @drdanchoi @813JAFERD @ercoderguy @Reese_Tassey @sonodoc99 @wilfordgibsom @KatieOrrico ...
6/ @SunnyJhaMD @JenniTelesz @purviparikhmd @movinmeat @ERGoddessMD @ACEPNow @ASALifeline @RadiologyACR @AAOS1 @AmerMedicalAssn @ahahospitals @californiaacep @WaysMeansCmte @SenBillCassidy @RepRaulRuizMD @RepKevinBrady
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