The Centers for Medicare & Medicaid Services (CMS) released an audit showing Aetna Health of Texas miscalculated a key metric and was not following federal guidelines as set out by the No Surprises Act.
The audit (PDF) is the first report looking at No Surprises Act compliance from health plans and confirms certain suspicions among providers that payers are not following significant reimbursement rules and regulations. It evaluated air ambulance claims in the state from Jan. 1, 2022 through June 10, 2022.
“The general consensus from my clients, is that even though they are not ambulance providers, it validated a lot of what they’ve been experiencing in terms of payer noncompliance,” said Jeffrey Davis, health policy director for McDermott Consulting.
He said the audit shows the health plan did not provide contact information and necessary information during the open negotiations process. Aetna also miscalculated the qualifying payment amount (QPA), both in its favor and in the providers’ favor, a surprising revelation.
The report found the QPA was not calculated using contracted rates; it was instead calculated by actual paid claims amounts. The QPA is a factor in the independent resolution process and helps determine patient cost-sharing.
“To me, this shows a lack of understanding, lack of clarity about how to calculate the QPA,” said Davis. “And the QPAs themselves can be all over the map. The data coming in shows the median prevailing offer … is 300% to 400% in some cases of the QPA. This is a very complicated, very messy process, and this shows that the QPA itself is not a number that’s really reliable.”
It’s unclear why an audit of Aetna Health of Texas was released first, and what audits of insurers may be next.
The No Surprises Act was passed in January 2022 to eliminate unexpected bills for consumers when they require emergency care. The legislation allowed all parties to settle payment disputes for out-of-network care during an independent dispute resolution, a contentious and flawed process many argue.
“This routine audit took place during the first six months of 2022, following the initial implementation of the requirements," said a CVS Health spokesperson in a statement. "We addressed all the report’s findings to CMS’ satisfaction."
Davis noted the company’s statement does not address whether the health plan, and others like it, are still violating federal requirements or not.
“I would venture to say things have not improved since then, based on anecdotal feedback I’ve received from providers and complaints that have been submitted to the departments about payer non-compliance,” he said, adding that many providers would like to see more enforcement for the rules and greater assurances health plans pay what they owe once an IDR settlement is reached.
A CMS rule aimed at making operational improvements to the independent dispute resolution process, originally slated for this summer, has now been pushed to November and may not be in effect until mid-2025. More clarity is expected to be issued from CMS in March regarding air ambulance services.
Aetna of Texas may be subject to future audits, the report says.