April 19, 2022
Area(s) of Interest:
Out of Network Billing
On Friday, April 15, 2022, the Centers for Medicare and Medicaid Services (CMS) opened the long-awaited federal Independent Dispute Resolution (IDR) process called for under the No Surprises Act (NSA), through which providers and payors can resolve payment disputes for certain out-of-network charges.
The NSA was designed to eliminate surprise medical bills for patients enrolled in group health plans and health insurance policies including self-funded/ERISA health benefit plans, who receive: (1) covered non-emergency services by out-of-network providers at in-network facilities, or (2) emergency services by out-of-network providers.
It is important to note that the NSA does not supersede state laws addressing provider reimbursement, the calculation of enrollee cost-sharing, and dispute resolution, such as California’s AB 72, which applies to out-of-network non-emergency services for state-regulated health plans and insurers. The AB 72 Independent Dispute Resolution Process (IDRP) will continue to be available in the same situations as before. Where AB 72 applies, providers will not be able to access the new federal IDR process.
The California Department of Managed Health Care (DMHC) has also confirmed with CMS that California’s Knox-Keene Act also takes precedence over the federal IDR process. Therefore, DMHC-licensed health plans must continue to comply with California law regarding provider reimbursement, the calculation of enrollee cost-sharing, and dispute resolution for out-of-network emergency services.
No similar guidance exists, however, with respect to insurance policies regulated by the California Department of Insurance (CDI). Accordingly, the federal IDR process will presumably be made available with respect to payment disputes involving out-of-network emergency services provided to CDI enrollees. NSA standards for calculating enrollee cost-sharing will also apply.
Services provided to patients enrolled in self-funded/ERISA health benefit plans will be governed by the NSA and need to follow the federal IDR process for dispute resolution.
In order to access the federal IDR, either the provider or payor must first initiate a required 30-business-day open negotiation period. At the end of the open negotiation period, if the parties cannot agree on an appropriate out-of-network payment, the initiating party has four business days to file a dispute via the federal IDR portal. Parties whose open negotiation period expired before April 15, 2022, now have 15 business days from the portal’s launch to file an IDR initiation notice.
Once the IDR process has begun, the disputing parties can continue to negotiate until the IDR entity makes a determination. If the disputing parties experience extenuating circumstances during the IDR process that prohibit them from complying with deadlines to submit information, they may email FederalIDRQuestions@cms.hhs.gov to receive a Request for Extension Due to Extenuating Circumstances form and instructions for next steps.
For more details on the NSA and its payment processes, including the IDR, register for the American Medical Association (AMA) webinar, “Out-of-network payment process under the No Surprises Act,” on Thursday, April 21, 2022, at 9:30am PT.
To learn more about the IDR process, visit cms.gov/nosurprises.
Additional Information and Resources: