Author Archive for Adrienne Frederick – Page 2

Labor, HHS, and Treasury Release Surprise Billing “Final Rules”: 3 Key Takeaways

On Friday, August 19th, the U.S. Departments of Labor, Health and Human Services, and Treasury (“the Departments”) released a final rule, revising certain provisions from the July and October 2021 interim final rules that had previously been issued to implement the No Surprises Act. The final rule includes important alterations to the previously issued interim final rules. Here are 3 key areas of importance:

  • The Departments Place New Obligations on Health Plans Regarding of Provision of the QPA for “Downcoded” Claims
    In response to the advocacy efforts of EDPMA and its partners, the Departments recognized the negative impact that the payer practice of inappropriate downcoding can have on the basic fairness of Federal independent dispute resolution (IDR). To address these concerns, the Departments took several steps.
    • The Departments codified their previously articulated definition of “downcoding” as “the alteration by a plan or issuer of a service code to another service code, or the alteration, addition, or removal by a plan or issuer of a modifier, if the changed code or modifier is associated with a lower qualifying payment amount than the service code or modifier billed by the provider, facility, or provider of air ambulance services.”
    • The Departments finalized that for claims to which the No Surprises Act is applicable, if a plan or issuer downcodes a claim that when the plan or issuer issues the initial payment, the plan or issuer must:
      • Provide a statement that the service code or modifier billed by the provider, facility, or provider of air ambulance was downcoded
      • Provide an explanation of why the claim was downcoded (including a description of which codes were altered/removed/modified)
      • Provide the amount that would have been the QPA had the downcoding not occurred.

After extensive advocacy by EDPMA and others on this issue, the Departments acknowledged that these requirements were necessary because “it is important for providers and facilities to know whether the plan or issuer has downcoded a particular claim that is subject to the balance billing protections in the No Surprises Act to ensure that providers receive information that may be relevant to the open negotiation process and that could inform a provider’s offer in the Federal IDR process, and which the provider has no other means of ascertaining.”

  • The Departments Formalized Past Guidance Making it Clear that Plans/Issuers Cannot Force Providers/Facilities to Initiate Open Negotiation Via Payer-Controlled Mechanisms
    After EDPMA and its partners informed the Departments of the frequent health plan practice of attempting to force providers and facilities to use health plan-created portals in order to initiate the “open negotiation” phase of payment resolution created under the No Surprises Act, the Departments affirmed their past guidance which makes clear that plans cannot require that providers utilize any method or mechanism other than proper submission of the standard Initiation of Open Negotiation form as articulated under the Departments’ rules in order to properly initiate open negotiation. In this final rule, the Departments directly state, “if a provider, facility, or provider of air ambulance services sends the standard notice of initiation of open negotiation to the email address identified by the plan or issuer in the notice of denial of payment or initial payment, that transmission would satisfy the regulatory requirement to provide notice to the opposing party (so long as the provider, facility, or provider of air ambulance services also sends the notice free of charge in paper form upon request).”

The Departments acknowledged that health plans can encourage use of portals and other web-based mechanisms but went on to state that “a plan or issuer cannot refuse to accept the standard notice of initiation of open negotiation from a provider, facility, or provider of air ambulance because the provider or facility did not utilize the plan’s or issuer’s online portal when the standard notice of initiation of open negotiation is provided in a manner consistent with the requirements of the July 2021 and October 2021 interim final rules.”

  • The Departments Responded to the TMA Litigation Outcome By Retracting its “Presumptive” QPA Policy But Finalizes Other “Additional Information” Evaluation Standards
    Throughout the final rule, the Departments acknowledge the outcome of the court ruling in favor of the Texas Medical Association. In doing so, the Departments rescinded the previous policies that the qualifying payment amount (QPA) is a presumed appropriate payment amount as well as striking the provision that directed arbiters to select the IDR offer that was closest to the QPA.  The Departments explicitly state, “these final rules do not require certified IDR entities to default to the offer closest to the QPA or to apply a presumption in favor of that offer.”

In its place however, the Departments finalized notable provisions that serve to bolster the relevance of the QPA in Federal IDR.

    • First, the Departments finalized that any “additional information” that is submitted by the disputing parties must meet its standard as “credible” and that certified IDR entities must evaluate whether the “additional information” submitted “relates to” the offer in order to be considered as part of the payment determination along with the QPA.
    • Second, the Departments finalized a new policy that certified IDR entities must avoid considering “additional information” that could result in “double counting.” The Departments state, “The certified IDR entity should consider whether the additional information is already accounted for in the QPA and should not give weight to information related to a factor if the certified IDR entity determines the information was already accounted for in the calculation of the QPA, to avoid weighting the same information twice,” as well as that “if the parties submit information related to more than one of the additional factors, the certified IDR entity should consider whether the information submitted regarding those factors is already accounted for by information submitted relating to other credible information submitted to the certified IDR entity in relation to another factor and, if so, should not weigh this information more than once.”

      As members are digesting the content of the final rule, EDPMA is actively listening to its membership and hears the concern about the new “double counting” standard that seems to be insufficiently-defined, poorly-conceived, duplicative of common sense, and therefore, subject to manipulation by the health plans.  Further, because the Departments are requiring a written rationale from the certified IDR entities every time they consider “additional information” as to why that additional information was not accounted for elsewhere, we understand our membership is extremely concerned that the Departments have provided certified IDR entities with an incentive to dismiss legitimate “additional information” simply because the already-stressed certified IDR entities seek to avoid the administrative burden of providing a written defense of how and why “additional information” used for making the payment determination does not result in double counting.

A link to the full rule can be accessed via this link. EDPMA, as part of the EDPMA/ACEP steering committee, is continuing to analyze the new provisions and consult with partners on next steps. We will keep you updated with additional advocacy efforts and opportunities.

Tri-Agencies Release Final Rule

On Friday, August 19, 2022, The U.S. Departments of Labor, Health and Human Services, and the Treasury this afternoon released a final rule further implementing provision of the No Surprises Act.

This rule addresses the IDR components of the legislation and responds to the federal court ruling from earlier this year regarding the approach that arbiters must take when making a payment determination in federal IDR.

NOTE: this is separate from the proposed rule which has cleared OMB and we are expecting soon, which will focus on the Advanced EOB provisions of the NSA as well as “Other Provisions.”

Additional resources:

Stay tuned for additional information and analysis.


EDPMA Joins Coalition Urging Congress to Pass CF Adjustment for 2023 and Wave PAYGO Requirement

On July 27 EDPMA joined medical societies urging Congress to pass legislation that provides at least a 4.5% CF adjustment for 2023 and waives the 4% statutory PAYGO requirement. We also ask for legislation to provide a one-year inflationary update based on the Medicare Economic Index. These important policy changes will undoubtedly provide our members with crucial short-term fiscal stability while simultaneously laying the foundation for necessary long-term payment reforms.  The letter can be found here.

EDPMA Concerned About Systemic Denial and Delay In Payment by Payers Affecting the Delivery of Emergency Care

McLean, Virginia – The Emergency Department Practice Management Association (EDPMA) is concerned that payers are denying payments to emergency medicine physicians for essential and lifesaving care they provide to patients. EDPMA believes that emergency physicians should be able to deliver high-quality, cost effective care in the emergency department and that payers should reimburse highly-trained emergency physicians based on a patient’s presenting symptoms.


However, many payers prioritize profits over patient care with the systemic practice to unnecessarily delay, deny, or reduce payments. EDPMA believes this is wrong and advocates on the regulatory, federal, and state levels to combat this practice on behalf of its members.


EDPMA also supports the efforts of our member organizations to advocate on behalf of their emergency physicians, such as Fremont Emergency Services’ litigation to hold UnitedHealthcare accountable for its policy to withhold payment to ER doctors after services have been rendered. In this vein, we support our colleague’s efforts to advocate for emergency physicians and patients by any means necessary, including litigation.


“EDPMA continues to hold payers accountable for systemic practices that do not acknowledge or compensate for medical decision making in the emergency department,” says Don Powell, DO, FACEP, EDPMA Chair of the Board. “We strongly believe that emergency physicians should be fairly reimbursed for the delivery of emergency care, and payers should do their part to not undermine the emergency medical health care delivery system or the overall health of our healthcare system. EDPMA is in the business of emergency medicine and will continue to advocate for its members and patients.”


The Emergency Department Practice Management Association (EDPMA) is the nation’s largest professional physician trade association focused on the delivery of high-quality, cost-effective care in the emergency department. EDPMA’s membership includes emergency medicine physician groups of all sizes, as well as billing, coding, and other professional support organizations that assist healthcare providers in our nation’s emergency departments. Together, EDPMA’s members deliver (or directly support) health care for about half of the 146 million patients that visit U.S. emergency
departments each year. Visit


Cathey Wise
703.506.3282 (direct) l 817.905.3310 (cell)

CMS Releases CY 2023 Medicare Physician Fee Schedule Proposed Rule

This afternoon, the Centers for Medicare and Medicaid Services (CMS) released the calendar year (CY) 2023 Medicare Physician Fee Schedule (MPFS) proposed rule.  For CY 2023, CMS proposes an MPFS conversion factor of $33.0775. That represents a 4.42% reduction from the CY 2022 MPFS conversion factor due to the expiring 3.0% boost to the conversion factor provided by Congress for CY 2022 as well as an additional budget neutrality adjustment generated by the CY 2023 proposed policies.

  • Emergency Medicine Overall Impact. CMS estimated that the overall impact of the rule on emergency medicine is a 1% increase in payments. However, note that this estimate does not factor in the expiring CY 2022 congressionally-mandated 3% boost to the conversion factor.
  • ED E/M Codes: Generally speaking, CMS proposes to adopt the revised CPT documentation guidelines for emergency department (ED) evaluation and management (E/M) visits. These changes are intended to align documentation for all E/M code sets (other than critical care services) with the documentation guidelines adopted for office and outpatient E/Ms in CY 2021. (For more information on the ED E/M documentation guideline changes coming January 1, 2023, see information from AMA CPT via this link.)

Because of these documentation guideline changes, the AMA RUC also embarked on a revaluation of all affected codes sets. In this proposed rule, CMS proposes to accept the values for emergency department (ED) evaluation and management (E/M) services as recommended by the AMA RUC for CPT 99281, 99282, 99283, and 99285.  However, CMS rejected the RUC recommendation of 2.60 for CPT 99284 and instead proposes to maintain the current work RVU of 2.74.

  • Split (or Shared) Visits. CMS had previously finalized a new January 1, 2023 billing policy for instances in which a physician delivers an E/M service along with a non-physician practitioner. As EDPMA requested, CMS has delayed the policy that would have based the determination of the billing practitioner solely on time. This policy is proposed for delay through January 1, 2024 while CMS collects additional input.
  • QPP. Per usual, CMS proposes modifications to the reporting requirements under the Quality Payment Program (QPP), including the Merit-based Incentive Payment System. As a reminder, CY 2023 reporting under the QPP will affect payment adjustments for services furnished in CY 2025.

EDPMA will continue to analyze the proposed rule and provide additional details. EDPMA plans to comment on the proposed rule before the end of the 60-day comment period.

  • A link to the full rule can be found here.
  • A CMS press release is available here.
  • A CMS fact sheet can be accessed here.
  • CMS also provided additional resources on the CY 2023 QPP policies in a zip file available here.

News Alert: EDPMA-ACEP Letter to Tri Agencies Regarding NSA Billing Compliance Issues

Yesterday, EDPMA and ACEP sent a letter to Departments of HHS, Labor and Treasury asking for action to ensure patients are taken out of the middle of payment disputes with health plans. This letter is a follow-up to the April 25 letter and meeting with CCIIO where EDPMA and ACEP shared continued concerns about emergency physicians’ difficulty in obtaining information from plans and insurers as required by the No Surprises Act. The full letter can be found here.
We will continue to monitor NSA implementation issues and advocate for you!

CMS Releases No Surprises Act Checklist of Payer Requirements

EDPMA in our partnership efforts with the American College of Emergency Physicians (ACEP) have worked to highlight the issues our members are experiencing with health plan compliance with their obligations under the No Surprises Act.  After sending multiple letters with examples of health plan non-compliance and meeting with staff from the Center for Consumer Information and Insurance Oversight (CCIIO), EDPMA is pleased to announce that CCIIO has released a new guidance document, Federal Independent Dispute Resolution Process Checklist of requirements for group health plans and group and individual health insurance issuers.

The full document can be accessed here.

EDPMA and ACEP Meet with CMS/CCIIO Staff To Advocate For You Re: Implementation of the No Surprises Act

EDPMA’s members consistently report that health plans are not providing federally required information to bill patients’ out-of-network services and to proceed with the federal Open Negotiations and Independent Dispute Resolution (IDR) processes that are part of the No Surprises Act.  To advocate on your behalf, we wrote a letter to federal agencies last month that provided: 1) specific examples of health plan non-compliance; and 2)  policy recommendations that would help address these non-compliance issues. EDPMA thanks our members who shared their redacted data to support this advocacy effort.


Last week, EDPMA and ACEP met with the Center for Consumer Information and Insurance Oversight (CCIIO) at the Centers for Medicare & Medicaid Services (CMS) staff to follow-up on our letter.  During the meeting, we described to CCIIO what specific health plan non-compliance issues we are experiencing, provided specific recommendations, and also requested additional guidance on how we should proceed with the Open Negotiations and IDR processes when there is limited or missing information from health plans (information that was required by the first interim final rule implementing the No Surprises Act).  We also emphasized the critical need for strong enforcement to ensure health plans provide information as required by law.


CCIIO made two important points about complaints:

  1. If a complaint remains unresolved and the timelines around the Open Negotiation and IDR processes become difficult to adhere to, disputing parties can file for an extension.
  2. You are allowed to “batch” complaints against one health plan.  In other words, instead of submitting a complaint for each individual claim, you can submit all the complaints against one health plan at once.  This may help save time and speed up the time in which your complaints are processed and adjudicated by CMS.


CCIIO staff stated that they heard many of these issues before and have received many complaints from providers that health plans are not providing all the required information.  CCIIO also claimed they resolved about 25% of all complaints, and there is a significant backlog of unresolved complaints.  Further, they stated that when a complaint is resolved, they request documentation from the health plan and continue to work with them to systematically resolve similar complaints moving forward. While CCIIO confirmed they are hosting internal conversations about how to enforce non-compliance, they did not offer specifics on enforcement processes or outcomes.


We believe the meeting was productive and we are reassured that CCIIO is acutely aware of these issues and is taking them seriously. Because CCIIO did not commit to adopting our policy recommendations, we will continue to follow-up with CCIIO on these requests.


As always, EDPMA has your back by advocating on your behalf and providing the resources you need to manage a successful business.


As a reminder, you can submit billing complaints by clicking here or by contacting the No Surprises Help Desk at 1-800-985-3059.

May 9: EDPMA Data Collection Project Webinar for Skeptics and Analysts

As the saying goes, “Data is King (or Queen)!” And legislators and regulators are moved to action by data and not anecdotes.

In conjunction with ACEP to better advocate for our members and the emergency medicine specialty, we are collecting data on your out-of-network (OON) payments focused on the Qualifying Payment Amount (QPA). This project will evaluate whether major payors are following the law by providing QPAs in writing for each CPT code that was paid or denied, assess the prevalence and size of variations between QPAs and the “Allowed Amounts” for OON payments and more. See the data collection Excel tool and Frequently Asked Questions about this project.

We understand there are questions about the requested data, how the data will be used and concerns about privacy and antitrust issues.

We get it!

That’s why EDPMA will host an informational webinar this Monday, May 9 at 1pm EDT to answer these questions and more for compliance managers, data analysists, business intelligence teams and skeptics. This webinar is open to both members and non-members.

Ed Gaines, JD and Greg Hufstetler CPA, the outside data consultant, will review project details and answer your questions.

For more information and to register, click here.

EDPMA-ACEP Letter on NSA Billing Compliance Issues

On Monday, April 25, EDPMA and ACEP sent a letter to the Departments of HHS, Labor and Treasury highlighting how health plans have not supplied basic information required by the NSA when paying for patient care services. The letter can be found here.