Insurers and providers are disagreeing over the cost of out-of-network services and turning to dispute resolution to work out their differences far more often than Congress anticipated when it passed a law to prevent surprise bills, according to recently released CMS data.
But, CMS data shows, there were more than 90,000 disputes initiated in less than six months.
Envision estimates about 13% of services in 2022 were reimbursed at a rate lower than Medicare rates compared to just 2% in 2021.We’ve seen some pretty strange QPAs which frankly I don’t think pass the smell test," said Patrick Velliky, vice president of government affairs.We have a high volume of QPAs from different payers that are either, to the penny, the same amount or up to 25% below the Medicare rate for the same service in the same geography," he said.
It's "not because providers are trying to flood the IDR system with disputes. There’s a lack of information available to the providers in determining eligibility," he said. There are many more disputes than the department expected and determining whether those disputes are eligible for the federal process requires more time and processing, he said.
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