December 16, 2021
The Federal No SurprisesAct, which seeks to reduce unexpected medical bills for patients, is takingeffect as plans renew January 1, 2022. It brings many new regulations forhealth plans and providers, including new rules for a federal independentdispute resolution (IDR) process.
Here’s a brief overview tohelp you understand the dispute resolution rules and how we’ll be implementingthem.
Howit works
The IDR process is forhealth plans and providers, facilities, and air ambulance providers to followfor certain out-of-network claims when open negotiations don’t result in anagreed-upon payment amount. It will be entered into by both parties andoverseen by certified, independent entities.
All parties will berequired to meet deadlines, attest to no conflicts of interest, choosecertified independent dispute resolution entities, submit payment offers, andprovide additional information if needed.
FederalIDR portal
For claims subject to thefederal No Surprises Act, the IDR process will be managed through a dedicatedFederal IDR online portal. (Claims covered by WA law will continue to gothrough the existing state process.) The federal portal will handle all aspectsof the process, including notification, entity selection, documentationsubmission, and decision communication.
The following are some keyaspects of how the online portal will work:
- Batched itemsand services may be submitted and considered jointly as part of one paymentdetermination by a certified IDR. Claims may be batched together in one of twoways: (1) by batching claims for same or similar services between the sameprovider or facility and health plan within the same 30-business day period or(2) if the multiple claims are part of bundled payment where the health planmakes or denies an initial payment.
- IDR Entitiesmust presume that the qualifying payment amount (QPA) is the appropriate out ofnetwork payment amount and choose the offer that is closest to the QPA. They’reallowed to consider a limited number of additional factors (e.g., providerexperience, provider market share, patient acuity, contracting efforts) whendeciding if the QPA is not the appropriate amount.
- Fees for theIDR entity will be within a range set by the government and will be submittedto the entity at the beginning of the process. Upon conclusion, the IDR entitywill remit the winner’s payment. There is also an administrative fee that bothparties will pay for participation.
Additional informationabout the portal will become available over the next several months, includinginformation about how to initiate an independent dispute resolution process inthe federal portal.
Timeline
| Independent Dispute Resolution Action | Timeline |
| Initiate 30-business-day open negotiation period | 30 business days, starting on the day of initial payment or notice of denial of payment |
| Initiate independent dispute resolution process following failed open negotiation | 4 business days, starting the business day after the open negotiation period ends |
| Mutual agreement on certified independent dispute resolutions entity selection | 3 business days after the independent dispute resolution date |
| Departments select certified independent dispute resolution entity in the case of no conflict-free selection by parties | 6 business days after the independent dispute resolution date |
| Submit payment offers and additional information to certified independent dispute resolution entity | 10 business days after the date certified independent dispute resolution entity selection |
| Payment determination made | 30 business days after the date certified independent dispute resolution entity selection |
| Payment submitted to the applicable party | 30 business days after the payment determination |
Learn More
You can read the No Surprises Act rules, view the model notices, and review the CMS fact sheet for more detail.
We’ll be communicating moreabout the No Surprises Act in future issues of Provider News. Here are resourcesare available:
- Federal No Surprises Act Explained
- Understanding Provider Directory Requirements forthe No Surprises Act
- No SurprisesAct: Understanding Balance Billing Rules