Key Revisions Finalized for Federal IDR Processes Under No Surprises Act

The Departments of Health and Human Services, Labor, and Treasury and the Office of Personnel Management released a final rule May 28 to improve the federal independent dispute resolution (IDR) process under the No Surprises Act.

The final rule sets the administrative fee amount at $15 per party per dispute, an 85 percent reduction. If either party fails to pay the administrative fee or certified IDR entity fee by the time the party’s offer is due, that party’s offer will not be considered received and they will continue to be responsible for payment of the administrative and certified IDR entity fees.

The rule finalizes a requirement that payers subject to the federal IDR process must register with the departments and provide certain information on the application of the federal IDR process. The plan or issuer will then receive an IDR registration number. This registration will eventually take place in the new IDR Gateway, a centralized platform for managing disputes, which is launching in phases beginning this year.

To improve communication, the rule requires that payers communicate information to providers using specific claim adjustment reason codes and remittance advice remark codes when providing any paper or electronic remittance advice to an entity without a contractual relationship with the payer.

The final rule also implements several additional changes to the 30-business day open negotiation period. The open negotiation period begins on the date when the party submits the open negotiation notice and payment remittance or notice of denial of payment. To improve information exchange and efficiency during the open negotiation period, the notice must include content elements to help parties identify the item or service at issue and whether the federal IDR process applies. Additionally, the party in receipt of the notice must send a response by the 15th business day of the open negotiation period.

Batching provisions have also been amended to include an expanded set of circumstances. Batched determinations are now limited to 50 qualified line items in a single dispute. The rule also finalizes a revision to the types of extenuating circumstances in which the federal IDR process may be extended.

Certified IDR entities must now determine eligibility within five business days of final certified IDR entity selection and notify both disputing parties and the departments. The disputing parties are required to submit additional information to the certified IDR entity within five business days of the request for additional information or otherwise risk dismissal of their dispute.

“By improving transparency, streamlining dispute review, and ensuring consistent communication standards, we are helping all parties obtain timely, fair payment determinations while reducing administrative burdens,” Acting Secretary of Labor Keith Sonderling said in a press release. “Most importantly, these improvements support the continued protection of patients from surprise medical bills and reinforce our commitment to a simpler, more reliable health care system.”

Sources:

https://www.cms.gov/newsroom/fact-sheets/federal-independent-dispute-resolution-operations-final-rule

https://www.cms.gov/newsroom/press-releases/federal-rule-takes-aim-health-care-bureaucracy-reducing-dispute-fees-boosting-transparency