CMS cites Aetna in 1st No Surprises Act audit

https://www.beckerspayer.com/payer/cms-cites-aetna-in-1st-no-surprises-act-audit.html

Aetna failed to accurately calculate qualified payment amounts for air ambulance services, CMS’ first audit of an insurer’s No Surprises Act compliance found. 

The audit, issued May 29, examined the rates Aetna Health in Texas charged for an out-of-network air ambulance provider between January and June 2022. 

The No Surprises Act requires insurers to calculate a qualified payment rate for out-of-network emergency services. This rate is generally the median contracted rate the insurer has with other providers for similar services in the area. 

CMS’ audit found Aetna used the wrong methodology to calculate the qualified payment rates, calculating the amount based on claims paid rather than contracted rates. 

In its audit, CMS instructed Aetna to conduct a self-audit of all of the qualified payment amounts it calculated for air ambulance services in Texas during the audit period, and refund members if their cost-sharing should have been lower based on the correct payment amount. 

The agency also found that Aetna failed to give providers required notice that they may initiate the independent dispute resolution process within four days after the end of the open-negotiation process. Aetna also failed to share the qualified payment amount it calculated to providers in notice or denial of payment. 

“This routine audit took place during the first six months of 2022, following the initial implementation of the requirements,” an Aetna spokesperson said in a statement shared with Becker’s. “We addressed all the report’s findings to CMS’ satisfaction.” 

Aetna could be subject to more audits of its payment rates in the future, CMS said. 

The audit is the first examination CMS has published on an insurer’s compliance with the No Surprises Act. The bill passed at the end of 2020 in an effort to end surprise medical bills for emergency care. 

In February, the American Hospital Association called on CMS to up its oversight of payers compliance with the act, adding it is “deeply concerning that the departments have not completed a single audit of payers when the law has been in effect for nearly two full years.” 

Provider groups have expressed concerns that the act’s current enforcement and dispute resolution process favors payers. 

The law has faced several legal challenges, and a backlog of disputed claims. Data published in February found the number of disputes initiated during the first six months of 2023, were 13 times greater than federal agencies initially anticipated. 

Filed under: General Problems