Final Rule Goes into Effect October 25, 2022

By Devona Slater

Long promised information still leaves lots of questions that in the announcement states the government departments intend to finalize “at a later date.”

So what is in the final rule that we should know about?

  1.  The final rule officially removes the rebuttable presumption in favor of the Qualifying Payment Amount (QPA). Arbitrators are no longer obligated to use the closest QPA or assume that the QPA is accurate or reflective of the payment for the services. As you will remember, this is the result of the court victory from the Texas Medical Association. Arbitrators are not to accept the QPA as a reasonable payment but are to consider the initial list of factors (experience of the provider, market share of the provider health plan, patient acuity, teaching states, case mix and scope of services of the facility and prior good faith efforts made by the provider to get in network with the plan. They did specify that good faith efforts should be reflective over the past four years. Our advice is to set each of these elements up in your payor dispute template to ensure that each is addressed with your appeal.

  2. The final rule does require health plans to provide additional information when a claim is downcoded. When the initial payment is made, the insurance company must:

    1. Include a statement that the service code or modifier billed had been downcoded

    2. Explain why the claim was downcoded

    3. And finally, the QPA amount that would have been paid had the service not been downcoded.  

  3. The third thing we believe is most important is that the rule clearly states that it is NOT permissible for health plans to require the use of an online portal for providers to initiate the open negotiation period. While they can create portals, they cannot refuse to accept the standard notice of initiation from providers.

Clients have reported little success in the appeals process; unfortunately, I do not think the final rule will help change the success rates. I believe currently, the best thing for providers to do is to submit bulk requests and make it difficult for the health care plan. File formal complaints with your state insurance commissioner if the health plan does not adhere to the timelines or provided the required information. Unfortunately, I believe this is an uphill battle we will have to continue to fight.

The ACE Team,

© 2021, Auditing for Compliance & Education, Inc.