CMS cites Aetna errors in first No Surprises Act audit

The Centers for Medicare and Medicaid services released its first No Surprises Act audit, listing a number of errors in how Aetna’s Texas division calculated reimbursement rates for air ambulance services.

While the scope of the audit was very narrow, it shows how convoluted the reimbursement process is under the No Surprises Act, health policy experts said. The heavily litigated No Surprises Act, which went into effect in 2022, is designed to shield patients from high healthcare bills when a provider is unexpectedly out of their health plan’s network.

Related: Coming to a contract negotiation near you: the No Surprises Act

“This is a complicated process,” said Jack Hoadley, research professor emeritus of health policy at Georgetown University. “We have always talked about a number of aspects of the [independent dispute resolution process] being a learning curve for all parties. This is our first visualization into [qualifying payment amount] calculations, and it suggests this will also be a learning curve.”

CMS audited Aetna’s payments from Jan. 1, 2022, to June 10, 2022, for a narrow set of air ambulance services provided in Texas. The audit, released Thursday, analyzed the qualifying payment amount, which is used under the No Surprises Act to try to apply comparable in-network rates to out-of-network services.

An Aetna spokesperson said in a statement the routine audit took place in the first six months of the No Surprises Act implementation and Aetna addressed all the report’s findings to CMS’ satisfaction.

The qualifying payment amount aims to settle out-of-network payment disputes by estimating the median in-network contracted rate for the same service in the same geographic region. It is the subject of the third No Surprises Act lawsuit brought by the Texas Medical Association. The case is ongoing.

According to the audit, Aetna incorrectly calculated the qualifying payment amount for a handful of services, resulting in payments ranging from 73% below to 82% above the appropriate rate. The insurer used a claims-weighted median instead of a contract-weighted one, which is required by the statute.

Also, the insurer didn’t inform the air ambulance provider it could begin the dispute resolution process within four days after open negotiations ended, nor did it share the qualifying payment amount during the billing process, CMS found.

It’s notable that Aetna’s qualifying payment amounts were higher and lower than the correct calculations, said Loren Adler, fellow and associate director of the Center on Health Policy at the Brookings Institution.

The fact that some of Aetna’s qualifying payment amounts were artificially higher contradicts arguments from some providers who say insurers are systematically decreasing those amounts, Hoadley said.