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Health Law Highlights

CMS’ First No Surprises Audit Targets Aetna, Finds Some Noncompliance

Summary of article from Healthcare Dive, by Rebecca Pifer:

The CMS’ first audit under the No Surprises Act found Aetna in Texas noncompliant with several key requirements, particularly in its calculation of qualifying payment amounts (QPAs) for air ambulance services. Aetna used incorrect methodologies, leading to both overestimations and underestimations of QPAs, and failed to provide necessary disclosures to providers. This lack of compliance could hinder the arbitration process, already burdened with backlogs. Aetna has since corrected its practices and must self-audit QPA calculations from 2022 onwards. The audit highlights ongoing disputes over QPA methodologies, which have led to legal challenges and delays in the arbitration process.

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Health Law Highlights

Four Ways Price Transparency Will Transform Healthcare

Summary of article from D Magazine, by Dr. Eric Bricker:

The lack of healthcare price transparency presents a significant challenge, particularly for insured individuals with high out-of-pocket costs. The federal government has mandated hospitals to disclose prices, but compliance remains low. Some health insurance companies are now linking out-of-pocket costs with healthcare providers’ price and quality, incentivizing patients to opt for high-value care. Price transparency will enable fair treatment of payers, encourage competition among providers, and could potentially reduce healthcare costs. Improved transparency is also expected to enhance the quality of care, countering the current system that often incentivizes lower quality.

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Health Law Highlights

Providers Target Insurers in New Surprise Billing Legal Scuffles

From Bloomberg Law, by Sara Hansard:

  • Health care providers are increasingly suing insurers for not making timely arbitration award payments under the No Surprises Act, creating a new hurdle in the implementation of the billing dispute resolution system. These lawsuits are expected to rise as more claims move through the system and are potentially batched together.
  • The No Surprises Act’s federal online independent dispute resolution (IDR) portal has faced challenges, including large case backlogs and numerous shutdowns. As of June 2023, more than 490,000 disputes over out-of-network claims were submitted, with 61% remaining unresolved.
  • A significant consolidated lawsuit, Guardian Flight LLC v. Aetna Life Insurance Co., involves four air ambulance companies suing Aetna Inc. and Cigna Health and Life Insurance Co. for non-payment of claims following arbitration decisions. The companies claim that the insurers have failed to pay over $3 million in IDR awards.
  • Insurers are arguing that providers cannot file court cases to enforce IDR awards and that their only recourse is to file a complaint with the Centers for Medicare & Medicaid Services (CMS). CMS has stated that it takes the issue of late payments seriously and will impose civil monetary penalties if a violation is found.
  • There are complications and challenges in challenging arbitration awards, including the expensive cost of litigation. Some health care providers have found it difficult to determine whether to use the federal or state process for dispute resolution, further complicating the situation.