Health Plan Weekly

The Biden administration on Sept. 30 issued the latest interim final rule (IFR) to implement the No Surprises Act, and the regulation makes clear that arbitrators will have to use the qualifying payment amount (QPA) — a calculation largely based on median in-network reimbursement rates — as their starting point when settling disputed out-of-network claims. While payer groups praised the rule and provider groups slammed it, some health policy experts say the method outlined for handling payment disputes makes sense — though they caution that it’s unclear how the provider market will ultimately react, or whether costs and premiums will increase due to the No Surprises Act itself.

The IFR stipulates that “when making a payment determination…[arbitrators] must begin with the presumption that the QPA is the appropriate [out-of-network] amount,” according to an HHS fact sheet. “For the independent dispute resolution entity to deviate from the offer closest to the QPA, any information submitted must clearly demonstrate that the value of the item or service is materially different from the QPA.” The IFR also settles other key points such as the scope of federal external review on denied claims and the requirements for calculating good-faith estimates of the cost of care, which providers will soon have to give to patients before a major procedure takes place.

Although some health insurers notched record-high profits when the COVID-19 pandemic’s first wave drove down routine care utilization, those fiscal benefits do not appear to have translated into big compensation bumps for some of the highest-paid insurer CEOs.

Only two of the CEOs at the six largest publicly traded health insurers saw their total compensation increase in 2020 compared with 2019 — Cigna Corp.’s David Cordani and Anthem, Inc.’s Gail Boudreaux — while the other four saw decreases. Some Blue Cross Blue Shield insurers, however, gave their chief executives sizeable pay hikes, including a 109% raise for Blue Cross Blue Shield of Minnesota’s Craig Samitt and a 73% bump for Independence Blue Cross’ now-retired Daniel Hilferty.

✦ CMS issued guidance stipulating employer-sponsored health plans can’t deny benefits to customers who have not received a COVID-19 vaccine. However, self-funded plans can offer premium discounts to customers who have been inoculated, according to the FAQ, which was released Oct. 4. Delta Air Lines Inc. made headlines this summer by announcing it would require unvaccinated employees to pay a premium surcharge.

✦ Blue Cross and Blue Shield of North Carolina (Blue Cross NC) said it saved $112 million in lab test costs through its contract with Avalon Healthcare Solutions, a lab benefit management company. Blue Cross NC uses Avalon’s software to review lab test claims, meaning “the use of labs within the Blue Cross NC provider network now stands at 99% of all lab services, up from 86% before the company’s agreement with Avalon,” according to a press release. The insurer also said its use of Avalon’s technology “improved health outcomes through the reduction of inappropriate lab testing and better adherence to clinical guidelines.”

✦ Centene Corp. settled two more of its PBM-related cases, reaching settlements with Illinois and Arkansas’ attorneys general to pay the states more than $71 million combined. Centene has been sued by dozens of states that allege the Medicaid-focused carrier submitted inaccurate pharmaceutical reimbursement requests that failed to properly disclose the cost of pharmacy services. Centene will pay Illinois $56,717,652 and Arkansas $15,228,318.72, and it settled with Ohio and Mississippi in June. The firm previously said it has set aside $1.1 billion to settle litigation regarding its PBM practices.

✦ The Biden administration on Sept. 30 issued an interim final rule to further implement the No Surprises Act, the law that bans surprise medical billing. The rule drew swift condemnation from the Federation of American Hospitals (FAH) but praise from insurer trade group AHIP. The FAH called it a “total miscue” that “inserts a government standard pricing scheme arbitrarily favoring insurers,” but AHIP said the rule’s approach to settling out-of-network claims between payers and providers “signals a strong commitment to consumer affordability and lower health care spending through an independent dispute resolution process.”

CareFirst BlueCross BlueShield, a mid-Atlantic, nonprofit Blues affiliate, recently unveiled a new, plan-owned and operated virtual care service, CloseKnit. CareFirst tells AIS Health that CloseKnit will offer services including “urgent care, behavioral and mental health, care coordination, [and] insurance navigation,” but the insurer hopes most of all that CloseKnit will make primary care more available to its members.

CloseKnit will include a proprietary mobile app. CareFirst hired veteran health care executive Mary Jane Favazza to run the new venture. Favazza’s last role was as general manager of Haven, the health care joint venture that JP Morgan Chase Co., Berkshire Hathaway and Amazon shuttered in January.