Robert Chavez, MD
President, IEPC
Providence Little Company
of Mary Medical Center Torrance

Hello friends and colleagues,

It is that time of year when your RCM company of CFO should be sending out letters to your OON payers to adjust the qualified payment amount (QPA). The QPA is supposed to be equivalent to the Median-In Network Rate for a given insurance payer. It is subject to be an annual inflationary adjustment starting in 2019. When adjusting for inflation, this should be +24.7% for 2025. This is important because it is one of the criteria utilized in the IDR process and sets your patients cost sharing amounts for a given year. You can also make use of this increase during during your IDR open negotiation as well as your IDR submission.

Also, keep a close eye on your 2025 EOBs to look for a mandatory Medi-Cal rate increase for all Medi-Cal products. The rate increase should be equivalent to 90% of Medicare for E&M codes and 80% of Medicare for all procedures. It will obviously take some time for these rates to go into effect and I suspect we will not see the EOBs reflect the increase until after the first quarter. It would not hurt to send out a letter reminding your Medi-Cal entities of this rate increase, though they should all be aware. Once the increases go into effect, there should be retroactive “catch-up” checks to reimburse back to January 1, 2025 at the new increased rates.

Finally, keep an eye out for any updates affecting the 2.83% Medicare cuts that went into effect January 1, 2025. If Congress passes another continuing resolution, it may have a “Medicare Fix,” which would decrease the cut for the year. If this occurs, have your RCM company reach out to your payers and make sure they adjust their EOBs and check to see if any retroactive payments from Medicare are to be included. (Wishful thinking I know).