Bass, Berry & Sims attorney Jeff Davis discussed the ongoing implementation of the No Surprises Act, focusing on the debate between healthcare providers and payers over the independent dispute resolution (IDR) process used to settle disputes over out-of-network payment rates.

The initial rules, directed the IDR arbitrators to presume the qualifying payment amount (QPA) was the appropriate payment amount. After providers filed a lawsuit contending that this rule favored payers and amounted to a benchmark that wasn’t authorized by the act, the federal agencies issued final rules directing arbitrators to consider other information submitted by providers, in addition to the QPA.

Yet, Jeff said, it’s clear that “the starting point is still the QPA — entities should consider the QPA and then, if the providers submit additional information, they should also consider that — but only if it has not already been accounted for in the QPA. Also, there’s not much guidance in terms of how much weight the IDR entity should give to the additional information.”

Jeff also described how provider organizations may be confronted with QPAs based on “ghost rates,” artificially low rates that providers agree to only because they don’t provide the service in question. When payers calculate a QPA for the service, Jeff said, “They’re going to look at all these different contracts for the service and then find the median rate … If the payers include those lower rates, it’s going to bring down the median and the QPA.”

Jeff made his comments for the article, “No Surprises IDRs Stall, But New Rules More Likely to Favor Providers,” published on September 19 by Part B News and available online (subscription required).