FAIR Health to Launch Product to Support Federal Surprise Billing Law

October 21, 2021

At the start of the new year, FAIR Health will launch a product to support the Qualified Payment Amount (QPA) provisions of the No Surprises Act (NSA), the federal surprise billing law that takes effect on January 1, 2022. The new product is called FH^® NSA Reference File.

The federal NSA applies to health plans in states that do not have a specific state law concerning surprise bills, and to self-insured health plans that are not covered by such state laws. For plans subject to the federal law, FAIR Health will offer data and web-based tools to support the determination of a QPA value under the NSA.

The NSA will require plans to calculate patients’ cost-sharing responsibilities for certain surprise medical bills using the plan’s QPA. The QPA is the payor’s median contracted amount for each procedure code in each market and geographic area it covers. When payors have insufficient provider contracts to calculate the applicable median contract amount, they must use an independent database to calculate the QPA and determine the patient’s cost-sharing obligations. Plans can use FAIR Health data in the FH NSA Reference File to calculate the QPA in these situations. In addition, the data may inform the plan’s selection of an initial payment to out-of-network providers, potentially reducing disputes and the need for arbitration. The data may also prove useful for arbitration and dispute resolution.

The FH NSA Reference File makes available the following information:

• Median in-network allowed amount benchmark, developed from imputed allowed amounts for:
  • Professional—medical and anesthesia procedures and services billed through CPT^®1 codes and equipment and supplies billed through HCPCS codes;
  • Outpatient facility services billed through CPT codes; and
  • Inpatient facility services billed through ICD-10 procedure codes and revenue codes.
• Values will be provided for each procedure code at various levels of geographic aggregation:
  • Geozip (a geographic area defined by the first three digits of a zip code or groups of three-digit zip codes);
  • Metropolitan Statistical Area (MSA);
  • Non-MSA (all areas in a state that are not included in an MSA);
  • State;
  • Census region; and
  • National.

FAIR Health President Robin Gelburd stated: “FAIR Health data already serve as the official data source for surprise billing laws in multiple states. We are pleased now to be able to support aspects of the federal law, especially for plans that are unable to comply through the use of their own data.”

For more information on the FH NSA Reference File, contact FAIR Health by email at info@fairhealth.org or call 855-301-3247, Monday through Friday, 9 am to 6 pm ET.

^{1 CPT © 2020 American Medical Association (AMA). All rights reserved.}