CMS Notice: Payment Disputes Between Providers and Health Plans (Feb. 10, 2023)
Available at https://www.cms.gov/nosurprises/help-resolve-payment-disputes/payment-disputes-between-providers-and-health-plans
In response to the federal trial court decision vacating portions of the final regulations on the surprise billing independent dispute resolution (IDR) process (see our Checkpoint article), HHS’s Centers for Medicare & Medicaid Services (CMS) has directed certified IDR entities not to issue new payment determinations until they receive further guidance from the agencies. In addition, any payment determinations issued after February 6, 2023 (the date of the court order), are to be recalled. CMS explains that the agencies are in the process of evaluating and updating the federal IDR process guidance, systems, and related documents to make them consistent with the court order but provides no timeline for the updated guidance. The IDR process guidance was recently updated to reflect the final regulations, which were issued in August 2022 to address the factors that certified IDR entities may consider in selecting a party’s payment amount after the same federal trial court invalidated portions of the interim final regulations (see our Checkpoint article).
EBIA Comment: The CMS notice directs certified IDR entities to continue working through other parts of the IDR process as they wait for additional direction from the agencies. Presumably this means that disputing parties will still be able to submit notices of IDR initiation through the IDR portal, further exacerbating the growing backlog of disputes (see our Checkpoint article). Further guidance will be welcome. For more information, see EBIA’s Health Care Reform manual at Section XII.B.3 (“Surprise Medical Billing: Emergency and Non-Emergency Services”). See also EBIA’s Group Health Plan Mandates manual at Section XIII.B (“Patient Protections”) and EBIA’s Self-Insured Health Plans manual at Section XIII.C (“Federally Mandated Benefits”).
Contributing Editors: EBIA Staff.