Thread by @EdGainesIII

1/ Random musings on the #NoSurprisesAct final rule issued 8/19/22--sorry for the trade speak in advance but otherwise this string would be 50+--the "qualifying payment amount" serves 2 purposes--determine Pt cost sharing & as a factor in IDR; QPA by definition repeated in the...

2/ rule is the median allowed amount determined by health plans for same or similar svs. as of 1/1/19--adjusted for inflation; now my doc friend who used to be an actuary says the CPI on the QPA should be +20%--then how would over 90% of the claims surveyed by @ACEPNow & @EDPMA..

3/reflect that the QPA=the allowed amount in '22? Because the health plans are making up the QPA as they know their calculations are non-transparent to anyone--except if CMS audits & stakeholders have repeatedly requested same; but perhaps we are making progress; see the......

4/statement below from footnote 30 (p. 30)--Depts. are beginning 2 understand that the health plans are playing w/ the QPA & reiterated that initial OON payment should be 1 that the plan "reasonably intends to be payment in full"--progress? My Tweeps be the judge-more later...

5/ Now downcoding--health plans take the codes and/or modifiers billed & arbitrarily pay at lesser amounts based on bots/AI/ML or whatever Com Sci flavor of the week tells them to--has been a major issue for hospital & office practices--HUGE issue to @EmergencyDocs--here we are..

6/making progress--(hope you are sitting down)--@ACEP & @EDPMA many yrs of advocacy has produced results--Depts. have now defined "downcoding" for the 1st time--reasonable definition (below); plans must describe why they downcoded + provide the QPA of the claim if not downcoded

7/ Thx you/thx you @texmed & @AdamCorley--the house of medicine would be in an entirely different situation w/out your advocacy/litigation--No more "presumptive QPA policy" b/c the TX fed ct. vacated that rule--Depts. reiterated same, 2d sentence below---BTW: how's your weekend?

8/ Ok this is a potential major issue--Gov't payor rates by statute & rule are prohibited from being used by either party in IDR--except that the Depts. just gave the plans a "green light" to use prior contracted rates when those rates were stated as a percentage of Medicare....

9/To an unsophisticated adjudicator hearing that the plans were paying "a 125% of Medicare" may sound perfectly reasonable--it is not--the CMS fee schedule is down 60-70% since RBRVS in '92--we fought hard 2 keep CMS rates out & stakeholders should strongly comment, footnote 39:

10/Lots of important info buried in footnotes--footnote 40 (below)--don't bother taking Fed Employee Health Benefit (FEHB/Fed. Blue) plan benies (not in Medicare A or B) 65 or >claims into IDR if initial payment is at/near CMS rates--IDREs can't grant payment higher than CMS