As a facility-based, solo
practitioner in Dallas, I often feel
challenged to negotiate a fee
schedule with third-party payors
that ensures I am able to maintain a viable
practice, including a living wage for myself
and staff, as well as covering the overhead
expenses in my practice. With the passage
of the Federal No Surprises Act (NSA)
in December 2020, practices like mine
could face even greater challenges if the
current proposed legislation is adopted
without important future congressional
amendments and clarifi cations adopted
during the three-part agency rulemaking
process. The NSA seeks to establish new
and meaningful patient protections from
unanticipated out-of-network care for those
patients with high-deductible plans and will
limit cost-sharing. I believe all physicians
support taking the patient out of the
middle of disputes between providers
and health plans. With passage of the
NSA, the federal government has taken a
misguided step in accomplishing this goal.
Furthermore, as with most legislation, the
details that are absent in the legislation
are codifi ed through the rulemaking
process and are critical for ensuring all
parties know exactly how the measure will
be implemented.
The oversight agencies, the Centers for
Medicare & Medicaid Services (CMS), the
Department of Treasury, and Department
of Labor, issued an Interim Final Rule (IFR)
and requested comments to help inform
future rulemaking. Those requests for
comment can touch on a range of issues,
including the scope of the IFR, the process
for obtaining notice and consent, data on
urgent care centers, the impact of healthcare
consolidation on reimbursement
rates, how to improve the billing process to
identify NSA-related claims, and whether to
set a minimum initial payment rate, among
other topics.(1)
26 DALLAS MEDICAL JOURNAL • October 2021
The IFR for the No Surprises Act Regulation,
Part 1, was published in July 2021.
One aspect of the proposed rule focused
on patient protections against surprise
medical bills and determining out-of-network
provider payments through a Qualifying
Payment Amount (QPA). Because of
the way QPA is proposed to be calculated,
future payments will not accurately, without
intervention, refl ect median contracted
rates, or the market rate.
Unless changed, the current version
of the NSA allows for the median rate
provided by the insurer to be calculated
as the middle number, or, if there is an
even number, then the average of the
middle two contracted rates. This formula
excludes single contracts, out-of-network
median rates, and does not utilize thirdparty,
nonprofi t benchmarking entity median
rate data. This will heavily skew the
dollar amount below the lower of the two
benchmarks considered in our Texas informal
dispute resolution (IDR) process (50th
percentile of FAIR Health allowed). This
QPA methodology, as it stands, will create
economic hardship for small, medium, and
independent practices like mine. Not only
would it cost additional dollars and time
to request an IDR, but an arbitrator would
use benchmarks that are below the lower
benchmark currently used in the Texas
IDR.
ADVOCACY
Editorial: A Call to
Action for Physicians
to Comment on Federal
No Surprises Act
By Christopher Ryan Cook, DO,
FASA