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After nearly 9 months since the No Surprises Act, patients have become protected from receiving surprise medical bills, but payers and providers are still struggling with many twists and turn within this regulation. What we once thought was settled terms has been turned on its head. Do revenue codes really tell payers the location or type of item or service a patient received? Do modifiers 26 and TC simply separate the professional component for interpreting and reading the results from the use of the equipment and technician for performing the diagnostic study? While the law determines how to calculate a member’s cost-share and protects a patient from surprise medical bills, there is no uniformity on how to pay providers. Is the qualifying payment amount (QPA) fair? Sometimes a QPA doesn’t apply and state law applies. Identifying bills subject to a state and/or federal law is not always easy. When addressing payment both providers and payers are prohibited from introducing certain factors in the IDR process, but does this apply to open negotiations? Few regulations exist around the open negotiation process, but after 9 months providers and their representatives continue to struggle with rules around the process. However, payers have some challenges in this process as well. Providers and facilities should not be quick to dispute the payment without proper analysis first. However, payers should also be more open to negotiations during the process and take appropriate measures to consider the adverse effects of the IDR process.

State laws can sometimes be more expansive than federal law, but their applicability is often limited to mostly the fully-insured health plans with the exception of the few states or stances where the self-insured plan can opt into the state law. However, the state law is only applicable to those plans regulated by the state, so plans sold out of state would not apply. State payment standards may pay better than the federal law for providers, depending on the state, but time will tell if those payment standards will narrow to align with the federal QPA.

The challenge for providers is determining whether the QPA is fair. Payers are responsible for calculating the QPA, but providers and facilities have no verifiable way to determine whether the QPA was done correctly. However, do providers and facilities now have a better way to negotiate with payers after July 1st? What about payers? How can they determine if a facility or provider is offering a fair amount during open negotiations?

What is the official CPI-U adjustment for 2022, and how does it compare to inflation in 2022? Since the QPA is frozen in time with only annual adjustments going forward, will the CPI-U adjustments keep up with the medical economic index or other market basket research? Research has shown that utilization may be changing as well as insurance networks. Letters of Agreement between payers and providers may no longer have the same effect under the regulations.

Together, we will explore a brief overview of the law, including the many challenges and opportunities for the payers and providers.