Pre-Payment Negotiation Is Beneficial to Payors and Providers in Settling Surprise Bills

QPA’s controversial history in IDR

The role of the qualifying payment amount (QPA) in the independent dispute resolution (IDR) process has been debated since the No Surprises Act (NSA) was passed. The Interim Final Rule (IFR) issued September 30, 2021 provided detail on the NSA’s IDR process and required arbitrators to place higher importance on the QPA than other factors. The Texas Medical Association (TMA) filed a lawsuit arguing that arbitrators should consider the other factors included in the NSA, such as the doctor’s experience, the number of other providers in the market, and the severity of the patient’s illness, with equal importance to the QPA. In its decision on February 23, 2022, the Court agreed with the TMA about how the IDR entity should evaluate the QPA in relation to other factors. Most recently, the Final Rule issued on August 19, 2022 supported the Texas Court’s decision. However, TMA has again filed suit claiming the QPA remains too influential in the process relative to other considerations.

With all this uncertainty, payors, especially those basing their initial payments on QPA alone, may need to consider whether to adjust the strategy they use to process surprise bills.

Reach an agreement before payment

The best time to reach an agreement with a provider is before payment. Therefore, rather than make an initial payment and risk the provider rejecting it in favor of negotiation or arbitration, we encourage our clients to let us engage in pre-payment negotiations with the provider. When the negotiations are successful, the provider signs off and post-pay negotiation and arbitration are avoided.

Pre-payment negotiation saves time and resources

Reaching agreement before payment is beneficial to both payors and providers. A pre-payment agreement saves time and resources because the claim won’t have to be reworked. It also eliminates the potential for either side losing during the IDR process. When payors lose, they may end up paying much more than they offered, and when providers lose, they may receive a payment that is well under what they originally billed. Additionally, the losing party also incurs the arbitration fees.

Pre-payment negotiation helps keep payor and provider relationships amicable

As a claim goes through the NSA process from initial payment to post-pay negotiation to arbitration, the likelihood of contention between the payor and the provider increases. Pre-payment negotiation helps to maintain an amicable relationship as both sides work together to reach a fair agreement.

Flexibility is key to success in pre-payment negotiations

Regardless of the outcome of the new lawsuit, when negotiating on a claim-by-claim basis before payment, Claritev uses analytic tools and scripting to understand the provider’s position on all of the information an IDR entity can consider. We are most successful when this information is paired with client parameters that allow negotiation somewhat above the QPA.

Learn about Claritev’s End-to-End Surprise Billing service here >

The information provided on this website does not, and is not intended to, constitute legal advice; instead, all information, content, and materials available on this site are for general informational purposes. If you have questions about how the No Surprises Act applies to your organization, please consult your legal counsel.