CHA News

Tri-Agencies Reopen Dispute Resolution Process for Some Claims and Issue Guidance on QPA Calculation

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The departments of Health and Human Services, Labor, and Treasury (the Tri-Agencies) reopened the independent dispute resolution (IDR) process for new single payment disputes, including claims where services are bundled into one payment amount on Oct. 6, 2023. Accompanying guidance indicates that the IDR process for batched and air ambulance disputes remains suspended while the Tri-Agencies update their guidance and systems to reflect recent court orders that stem from recent rulings in the U.S. District Court for the Eastern District of Texas.   

Separately, the Tri-Agencies also issued guidance related to the calculation of the qualifying payment amount (QPA). The QPA serves as the basis for both calculating patient cost sharing in out-of-network situations covered under the No Surprises Act and serving as one of the factors IDR entities consider when resolving out-of-network payment disputes. This guidance is in response to a recent court decision vacating CMS’ July 2021 rule that allowed health plans to artificially deflate the QPA.  

In the absence of guidance from the agency, the Tri-Agencies are requiring health plans to “calculate QPAs in a manner consistent with the statutes and regulations that remain in effect after the…vacatur.” However, the guidance provides enforcement discretion until May 1, 2024, due to “the significant challenges associated with recalculation.”  

CHA is reviewing the guidance and will provide feedback to the Tri-Agencies stressing the deleterious effect this delay will have on providers.