Agencies Update Surprise Billing IDR Process Guidance for Final Regulations and Release 2023 Fee Amounts

The DOL, HHS, and IRS have updated the independent dispute resolution (IDR) process guidance used by plans, insurers, providers, and certified IDR entities in resolving claims for payment for out-of-network services through the federal IDR process. The agencies have also released IDR fee amounts for the 2023 calendar year. The process guidance has been updated to reflect final regulations, issued in August 2022, that addressed the factors that certified IDR entities may consider in selecting a party’s payment amount and additional disclosure requirements for plans and insurers that “downcode” billed claims (see our Checkpoint article). The updated process guides are effective as of October 25, 2022, and apply to items and services furnished by an out-of-network provider on or after that date, for plan or policy years beginning on or after January 1, 2022.

The updated fee guidance sets forth the administrative fee for participating in the federal IDR process in 2023 as well as the allowable ranges for certified IDR entity fees related to single and batched determinations. The administrative fee—$50 in 2023—is based on the cost to the agencies to carry out the IDR process and is paid by each party upon initiation of the process. Each party must pay a certified IDR entity fee to the certified IDR entity (the fee will be refunded to the prevailing party). For 2023, certified entities may charge a fee ranging from $200–$700 for single determinations and from $268–$938 for batched determinations. The guidance also provides a process by which certified IDR entities may seek approval to charge fees outside the permitted range.

EBIA Comment: The IDR process guides provide tailored information on the IDR process for certified IDR entities and for disputing parties. Plans and insurers will want to quickly familiarize themselves with the updated guidance due to its immediate effective date. For more information, see EBIA’s Health Care Reform manual at Sections XII.B.3 (“Surprise Medical Billing: Emergency and Non-Emergency Services”) and XII.B.4 (“Surprise Air Ambulance Billing”) and EBIA’s Group Health Plan Mandates manual at Section XII.B (“Patient Protections”). See also EBIA’s Self-Insured Health Plans manual at Section XIII.C (“Federally Mandated Benefits”).

Contributing Editors: EBIA Staff.