Agency Report Showing High Demand for Surprise Billing IDR Provides Data by State, CPT Code

The DOL, HHS, and IRS have jointly issued a report with usage data on the surprise billing independent dispute resolution (IDR) process created when the Consolidated Appropriations Act, 2021 (CAA, 2021) expanded patient protections to shield individuals from surprise bills for certain out-of-network emergency and non-emergency services. The CAA, 2021 and regulations addressing procedural aspects of plan payments to nonparticipating providers, including the role of certified IDR entities, require the agencies to post quarterly reports highlighting IDR activity (see our Checkpoint article). The data for the reports is drawn from certified IDR entities and the HHS federal IDR portal, which opened April 15, 2022 (see our Checkpoint article).

The agencies have released a report representing two quarters of data from April 15–September 30, 2022. Notably, disputing parties initiated 90,078 disputes through the IDR portal, but only 23,107 were closed during the period, often because of processing delays when parties contested their disputes’ eligibility for the federal IDR process. Of the closed disputes, over two-thirds of those relating to emergency and non-emergency services were found ineligible for the federal IDR process, and nearly half of closed air ambulance disputes were found ineligible. Explaining that eligibility depends on several factors, including determining state versus federal jurisdiction, correct batching and bundling, compliance with applicable time periods, and completion of open negotiations, the report points out that 22 states have state laws that protect consumers from surprise billing and provide a method for determining the payment amount in certain circumstances. A table listing disputes initiated by state reveals that 60% of all disputes were initiated in Texas, Florida, Georgia, Tennessee, and North Carolina, despite Texas, Florida, and Georgia having a state process that would apply to payment disputes of certain items and services. Another table that tracks disputes by the services provided based on Current Procedural Terminology (CPT) codes indicates that the most common CPT codes involved in disputes were emergency department service codes (66% of disputes), radiology codes (9% of disputes), and anesthesia codes (7% of disputes).

EBIA Comment: The agencies state that this initial, partial report was delayed because parties submitted significantly more disputes than the agencies initially estimated, and the IDR portal’s reporting functionality required substantial manual processing. The IDR administrative fee was increased for 2023 to reflect the rising volume of disputes and additional expenditures associated with the agencies’ enhanced role in conducting pre-eligibility reviews to address a growing backlog of disputes (see our Checkpoint article). 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 XIII.B (“Patient Protections”). See also EBIA’s Self-Insured Health Plans manual at Section XIII.C (“Federally Mandated Benefits”).

Contributing Editors: EBIA Staff.