JAMA Health Forum. 2022. JAMA Network. 2022 September 16.


Erin Lindsey Duffy1, Adam Biener2, Christopher Garmon3, Erin Trish1


1University of Southern California Leonard D. Schaeffer Center for Health Policy and Economics, Los Angeles

2Economics Department, Lafayette College, Easton, Pennsylvania

3Department of Public Affairs, University of Missouri–Kansas City, Kansas City

Importance The No Surprises Act (NSA), which took effect on January 1, 2022, applies a qualifying payment amount (QPA) as an out-of-network payment reference point. An understanding of how QPA measures compare with the in-network and out-of-network payments physicians received before the NSA implementation may be useful to policy makers and stakeholders.

Objective To estimate the QPA for geographic and funding markets and compare QPA estimates with in-network and out-of-network payments for 2019 emergency medicine claims.

Design, Setting, and Participants This cross-sectional study of US commercial insurance claims assessed the Health Care Cost Institute’s 2019 commercial professional emergency medicine claims (Current Procedural Terminology [CPT] codes 99281-99285 and 99291) and included enrollees in commercial health maintenance organizations, exclusive provider organizations, point of service, and preferred provider organizations self- funded and fully insured through Aetna, Humana, and some Blue Health Intelligence plans. Claims with missing or inconsistent data fields were excluded. Data were analyzed November 1, 2021, to April 7, 2022.

Main Outcomes and Measures The QPA was calculated as the median allowed amount of all observed claims within strata defined by geographic region, CPT code, and funding market. For each stratum, the ratio of mean in- network allowed amounts to QPAs and mean out-of-network allowed amounts to QPAs were calculated. Then the volume-weighted mean of these ratios was computed across CPT codes within each geographic and funding market stratum.

Results The analytic sample included 7 556 541 professional emergency claims with a mean (SD) allowed amount of $313 ($306) and mean (SD) QPA of $252 ($133). Among the 650 geographic and market strata in the sample, the mean in-network allowed amounts were 14% (ratio, 0.96) higher than the estimated QPA. For the subset of strata with a sufficient sample of out-of- network claims (n = 227), the mean out-of-network payments were 112% (ratio, 2.12) higher than the QPA. More generous out-of-network payments were from self-funded plans (120% [ratio, 2.20] higher than the QPA estimate) vs fully insured plans (43% [ratio, 1.43] higher than the QPA estimate). Mean in- network allowed amounts for nonphysician clinicians were 4% (ratio, 1.04) lower than the QPA, whereas mean in-network allowed amounts for physicians were 15% (ratio, 1.15) higher than the QPA estimates. These differences remained after adjusting for geographic region.

Conclusions and Relevance The findings of this cross-sectional study of US commercial insurance claims suggest that the NSA may have heterogeneous implications for out-of-network payments and negotiating leverage experienced by emergency medicine physicians in different geographic markets, with the potential for greater implications in the self-funded market.

View the study.