- April 3, 2023
- Alerts
CMS’ Resumes No Surprise Act Independent Dispute Resolution Process
On March 17, 2023, the Centers for Medicare and Medicaid Services (“CMS”) announced that independent dispute resolution (“IDR”) process called for in the Federal No Surprises Act should resume, and that the IDR entities could again make payment determinations in disputes between out-of-network providers and health plans that are subject to the NSA. CMS had previously paused this process on October 25, 2022 in order to update the IDR regulations, following the decision of a U.S. District Court in the Eastern District of Texas striking down parts of the interim final rules published by CMS. For the second time since the NSA became effective, the Court found that the rules placed too much weight on the Qualified Payment Amount (“QPA”) set by the health plans, contrary to Congress’ intent, and placed hurdles on consideration of other factors, including the qualifications of the provider and the difficulty or complexity of the particular procedure at issue, an imbalance which disadvantaged healthcare providers in the IDR process. This ruling prompted CMS to institute the hiatus as it again sought to update its guidance to comply with the law.
The new guidance from CMS instructs IDR entities to consider both the QPA (which is the median of the contracted rates recognized by the plan for the same or similar services) as well as additional permitted information relating to the offers submitted by the parties, and eliminates the previous requirement that such information could only be considered if several requirements are met: the information is “credible,” “relates to the offer submitted by either party,” and is not “already accounted for by the [QPA].” Going forward, the additional information providers submit in the IDR process will be on equal footing with the QPA.
When submitting disputes, providers should keep in mind that a significant backlog has accumulated for the IDR entities to review due to this pause. Furthermore, providers should note that the majority of payment determination notices from the IDR portal will now be coming from auto-reply-federalidrquestions@cms.hhs.gov.
Should you have any questions regarding the above, please contact the authors, or your regular Garfunkel Wild contact or email us at info@garfunkelwild.com.
The new guidance from CMS instructs IDR entities to consider both the QPA (which is the median of the contracted rates recognized by the plan for the same or similar services) as well as additional permitted information relating to the offers submitted by the parties, and eliminates the previous requirement that such information could only be considered if several requirements are met: the information is “credible,” “relates to the offer submitted by either party,” and is not “already accounted for by the [QPA].” Going forward, the additional information providers submit in the IDR process will be on equal footing with the QPA.
When submitting disputes, providers should keep in mind that a significant backlog has accumulated for the IDR entities to review due to this pause. Furthermore, providers should note that the majority of payment determination notices from the IDR portal will now be coming from auto-reply-federalidrquestions@cms.hhs.gov.
Should you have any questions regarding the above, please contact the authors, or your regular Garfunkel Wild contact or email us at info@garfunkelwild.com.