Methodology for calculating the Qualifying Payment Amount under the No Surprises Act sets up an environment “ripe for discrimination” against CRNAs.
By Jean Covillo, DNAP, CRNA, APRN
Managing Member, Excel Anesthesia, LLC
As published in the federal register, commercial payers are given the “green light” to discriminate against CRNAs by reducing payments for the same service.
When calculating the Qualifying Payment Amount (QPA), insurance companies are allowed to separately calculate this amount based on service code-modifier combinations- in other words, by provider “type.” There are separate QPAs recognized for each anesthesia delivery model since the QPA is calculated by taking the median allowable amount by “service code-modifier combination.” Service codes serve to define the delivery model. The QPA for nonmedically directed CRNAs will be calculated by the median specific to claims submitted under the QZ modifier code. Other anesthesia delivery model types such as medical direction or supervision will also have separately calculated QPAs specific to their service codes.
The federal rule states services administered by “similar providers” qualified to bill for the same service would be treated without prejudice with the caveat that market conditions may alter the amount negotiated. On the surface, this seems reasonable; however, when you drill down to the “methodology” used in the QPA calculation, you see that the separate buckets defining the same anesthesia services set up conditions ripe for discrimination.
The 2019 QZ commercial reimbursement survey showed a 24% disparity in commercial rates when the same services were billed under QZ. (See the video presentation on CRNA Commercial Reimbursement when billing under the Unique QZ modifier: https://youtu.be/XuMZg1PEHV0) It is, therefore, reasonable to assume discrimination is at play when the QPA amount for CRNAs is considerably less than physician-led practices even though both providers are billing for the exact same procedures and essentially the same services.
There is no reason to separately calculate the QPA for the median anesthesia rate per unit by service code-modifier combinations. CMS recognizes both CRNAs and Anesthesiologists as qualified to perform and bill for essentially the same services, and both providers receive the same reimbursement. The nondiscrimination provision of the ACA prohibits payers from discriminating against providers with disparate rates when both are qualified to perform the same services. As published in the federal register, the language gives commercial payers the “green light” to discriminate against CRNAs by offering lower rates “by provider types” when providing the same service.
Service codes that offer the same billable service should not have separate QPAs. The QZ study performed for services in 2019 shows a 24% disparity between CRNAs and Anesthesiologists, and most practice settings are affected by these policies. QZ is responsible for a third of all anesthesia claims submitted, and most practices, including physician-led practices, are billing nonmedically directed QZ services when medical direction criteria fail. All practice settings are affected by this type of discrimination.
Federal Register:..to calculate the QPA for anesthesia services furnished during 2022, these interim final rules require the plan or issuer to, first, take the median contracted rate for the anesthesia conversion factor (determined in accordance with the methodology for calculating median contracted rates for service code-modifier combinations) for the same or similar item or service as of January 31, 2019, and increase that amount to account for changes in the CPI-U, using the methodology described earlier in this section of the preamble.
Interim Final Rule text:
