America's Benefit Specialist January-February 2023

BENEFIT REPORTING

as third-party administrators, need to learn more about this and take more time before they submit to be sure all of the additional elements are included, which can influence an arbitrator to rule in favor of the health plan more frequently. FINAL RULE CLARIFICATIONS ON THE IDR PROCESS Clarifications in the Final Rule include downcoding. By defi nition, downcoding occurs when a payer alters a service code by changing it to another code or altering, adding or remov ing a modifier in a way that results in a lower QPA relative to the billed claims. The Final Rule requires payers to disclose to providers if a claim has been downcoded for the purpose of computing the QPA. If so, the payer must: a) provide a statement that codes or modifiers were down coded b) explain why a claim was downcoded, including a descrip tion of which codes or modifier were altered, added or removed c) specify the amount that would have been the QPA had the codes or modifiers not been downcoded. Another clarification in the Final Rule was on the QPA de termination/payment considerations for non-RBP plans. The Final Rule eliminates the rebuttable presumption standard. In addition, the Final Rule kept the central role for QPA and the standards that allow a CIDRE to choose an offer that “best reflects appropriate out of network payment.” The Final Rule begins with consideration of the QPA, then all other “credible” additional information, and then decides which rate best reflects the appropriate payment amount for the OON service without double counting. Despite the depart ments’ emphasis on considering the QPA, IDRES now have authority to give equal weight to the provider’s additional information (whether “credible” or not). Other final rule clarifications are related to federal arbi tration decisions. The Final Rule directs the IDRE to include in written decisions information used to determine that the “offer” selected best represented the value of the item or ser

vices, including the weight given to the QPA and any cred ible “additional information.” As part of the Final Rule, they released FAQs for self-insured plan QPA calculation. In the Final Rule, the departments explain how a SF group health plan should calculate a QPA when the plan offers multiple benefit package options that are administered by different TPAs. In addition, for RBP plans with no network, they provid ed for the applicability of surprise-billing protections. In the final rule, they stated that RBP plans will always be subject to surprise-billing requirements, but only in cases in which emergency care is furnished. NSA protections apply when an enrollee receives covered emergency care or air-ambulance services. In an RBP plan, patients would NOT be protected from OON bills for non-emergency care (because there can never be an in-network medical facility if the RBP plan has no network). Next month: pharmacy requirements. Sources: ACA FAQs, Part 49 www.dol.gov/agencies/ebsa/laws-and-regulations/laws/no-sur prises-act; www.cms.gov/nosurprises www.cms.gov/files/document/model-disclosure-notice-pa tient-protections-against-surprise-billing-providers-facili ties-health.pdf www.cms.gov/nosurprises/policies-and-resources/overview-of rules-fact-sheets www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insur ance-Protections/Prescription-Drug-Data-Collection Dorothy Cociu is the president of Advanced Benefit Consulting in Anaheim, California. Advanced Benefit Consulting & Aditi Group offer privacy and security training, consulta tion and implementation system assistance, as well as risk-assessment services on an ongoing basis. Author’s Note: I’d like to thank Marilyn Monahan of Monahan Law Office for her assistance with this article and our related seminars and webinars.

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