Robert Chavez, MD
President, IEPC

Providence Little Company of Mary Medical Center Torrance

Here is my pearl for this month. With regards to out of network payers, the No Surprise Act mandates annual Consumer Price Index-Urban (CPI-U) annual updates to the Qualified Payment Amount (QPA). Each year since the NSA statute was signed into law, the IRS has published an annual inflation update to the QPA payers are obligated to present when a group has an IDR claim against them. The statute states the QPA’s CPI-U adjustment is a cumulative increase from the “median allowed amount as of 1/1/2019.” The 2022 adjustment from 2019 was +6.485%. The 2022 adjustment from 2019 was 6.485%+7.685%=+14.6695%. The 2024 adjustment, in addition to the previous two adjustments, is calculated at a total of +20.89%. Therefore, when engaging in the IDR process, be sure to ask your OON health plans if they have made the mandated adjustments. If they do not respond or have not made the adjustments, then consider filing a complaint at FederalIDRQuestions@cms.hhs.gov. In addition, I asked my in-network payers if they had increased their QPA and would this lead to a higher reimbursement based on my current rates? The response to this question was mixed, but it was definitely worth asking.