ASA Supports Payer Accountability, More Robust Transparency in Coverage Regulations

The American Society of Anesthesiologists (ASA) submitted comments to the Centers for Medicare & Medicaid Services (CMS) in support of expanded regulatory oversight of payers. Effective transparency rules, ASA stated, will provide patients with meaningful information regarding out-of-pocket costs, while equipping anesthesiologists with actionable data to support fair contract negotiations.

Read ASA Comments.

Implemented in 2022, Transparency in Coverage regulations require payers to publicly post negotiated rates and contracts. But since 2022, these enormous data files have not met the expectations of physicians and their groups. An ASA internal analysis of payer information revealed that the files provided by insurers are often inconsistent, inaccurate, or too convoluted to provide reliable information. ASA has become increasingly alarmed that a lack of transparency has placed anesthesiologists at a competitive disadvantage to insurers who have significant amount of resources to assess these large data files.

In our comments, ASA offered support to CMS identifying and addressing the problem of “ghost” or “zombie” rates in the negotiated rate files. As the NSA and Independent Dispute Resolution (IDR) process have revealed, many insurers have included these “ghost” or “zombie” rates to artificially deflate the Qualified Payment Amount (QPA). A deflated QPA becomes even more problematic if insurers use the QPA amount as initial payment to providers, even though the NSA does not support this practice. Similar to previous court rulings addressing such practices, the proposed rule would curtail the posting of most “ghost” or “zombie” rates in public-facing documents.

ASA also encouraged CMS to develop safeguards related to the quality of data publicly posted. ASA described how some ASA members report that publicly-posted data may include outdated or inaccurate information. More than simply finalizing a common format for these files, ASA suggested CMS establish mechanisms to validate insurer contracts or, at a minimum, score those contracts on the quality and accuracy of previously disclosed negotiated rates. Far too often insurers have undermined efforts for greater transparency by providing confusing, overly complex, and, in some cases, inaccurate data.

ASA agreed with CMS’s underlying arguments that a utilization file provided by health plans would allow greater transparency regarding the types of services (and quantity of services) individual physicians provide. ASA supported CMS’s argument that a Utilization File would “reveal which providers are actively serving enrollees and delivering covered items and services within a plan’s or issuer’s network” and recognized the patient protections such a file would create. Moreover, ASA supported CMS’s proposal that “a group health plan or health insurance insurer [exclude] from each file a provider and their negotiated rate for an item or service if the plan or issuer determines it is unlikely that the provider would be reimbursed for the item or service given that provider’s area of specialty.” This not only aligns with legal decisions related to the NSA, but it also provides consumers and patients with more understandable information. ASA believes that the health insurance market will function more efficiently under this proposal. CMS should finalize its proposal for a health plan or insurer to exclude such rates from the public file. 

For more information on Transparency in Coverage regulations, please contact the ASA Department of Quality and Regulatory Affairs at [email protected].