According to CMS, the Consolidated Appropriations Act of 2021 established several new requirements for providers, facilities, and providers of air ambulance services to protect consumers from surprise medical bills. These requirements are collectively referred to as “No Surprises” rules. Among other things, these include prohibiting balance billing in certain circumstances and requiring disclosure about balance billing protections, requiring transparency around health care costs, providing consumer protections related to continuity of care, and establishing requirements related to provider directories.
These requirements generally apply to items and services provided to consumers enrolled in group health plans, group or individual health insurance coverage, and Federal Employees Health Benefits plans. The requirements for transparency of health care costs and the requirements related to the patient-provider dispute resolution process also apply to uninsured consumers.
Out-of-Network Provider Disputes of QPA
Blue Cross and Blue Shield of Alabama calculated the Qualifying Payment Amount (QPA) based off our January 31, 2019, allowances, the Census Bureau Metropolitan Statistical Areas (MSA) for the state of Alabama, and the U.S. City Average CPI-U from August of 2019, 2020 and 2021 depending on when the procedure codes were effective. For 2023 and after, these allowances will be adjusted effective January 1 of each calendar year and increases will be determined by the ratio set in the Consolidated Appropriations Act (CAA), “The factor will be the quotient of CPI-U for the current year divided by the CPI-U for the prior year.”
To calculate the QPA for anesthesia procedure codes, we took the median rate for the code and modifier as of January 31, 2019. The rate will then be increased by the CPI-U as discussed above. This new indexed median rate was multiplied by the base unit, time unit and physical modifier.
To calculate the air ambulance QPA, the median rate was increased by the CPI-U as discussed above. This indexed median rate is then multiplied by the number of loaded miles submitted on the claim.
In creating the QPA fee schedules, the allowances were not built off related codes. When a new code does not have relative value units or CMS pricing, the allowance could be determined by using related codes. A related code will also be used for pricing an unlisted code. All services are on a fee-for-service basis and Blue Cross did not use an eligible database to determine the QPA. Bonus and incentive payments were excluded from the QPA calculation.
Open Negotiation Process
To begin the Open Negotiation process, please complete the Intake Form and submit via fax to 205-733-7284 along with the Open Negotiation Notice and medical records. We will respond to your request via e-mail.
Independent Dispute Resolution (IDR) Process
To begin the Independent Dispute Resolution (IDR) process, please complete the Intake Form and email it to OpenNegotiationIDR@bcbsal.org along with the Notice of IDR Initiation. Please note that this can only be done after the 30 business-day negotiation period has ended and within four business days beginning on the 31st business day after the start of the Open Negotiation Period.