The Centers for Medicare & Medicaid Services released a fact sheet on Dec. 18 explaining the finalized administrative and certified Independent Dispute Resolution (IDR) entity fees associated with the use of the Federal IDR process under the No Surprises Act, implemented as a provision of the Consolidated Appropriations Act of 2021.
An Aug. 3 decision in Texas Medical Association v. U.S. Department of Health and Human Services (TMA IV) resulted in the halting of certain guidance used by the Departments of Health and Human Services, Labor, and Treasury to establish administrative fee amounts for the IDR process, impacting all disputes initiated since Jan. 1, 2023. The final rule addresses concerns from TMA IV regarding price transparency for administrative and certified IDR entity fees.
The final rule sets the administrative fee amount at $115 per party for disputes initiated on or after the effective date of Jan. 1, 2024. To arrive at this amount, the departments exercised a new methodology that divides the estimated expenditures to maintain the Federal IDR process by the estimated number of administrative fees expected to be paid to certified IDR entities within the year, rather than the estimated number of disputes closed, as originally proposed. To increase stability, the administrative fee will be updated no more frequently than once annually.
The final rule establishes fee ranges for certified IDR entities at $200 to $840 for single determinations and $268 to $1,173 for batched determinations. Additionally, for batched determinations exceeding 25 line items, certified IDR entities may set a fixed fee in the range of $75 to $250 for each increment of 25 dispute line items, beginning with the 26th line item. As with the administrative fee, the certified IDR entity fee ranges will be updated no more frequently than once annually.
Consistent with existing requirements, IDR entities will still be required to set their fees once per year within the provided ranges or to submit written requests for approval to set their fees outside of the established ranges. Certified IDR entities will also be allowed one additional time per year to update their fees, with approval from the Departments of Health and Human Services, Labor, and Treasury.
Moving forward, the final rule establishes that any changes to the administrative fees of IDR entity fee ranges will be published in notice and comment rulemaking rather than annually published guidance.
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