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Process Guide Issued for Surprise Billing Independent Dispute Resolution

EBIA  

EBIA  

Federal Independent Dispute Resolution (IDR) Process Guidance for Certified IDR Entities (Dec. 2021)

Available at https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Federal-Independent-Dispute-Resolution-Process-Guidance-for-Certified-IDR-Entities.pdf

The DOL, IRS, and HHS have issued a process guide for certified independent dispute resolution (IDR) entities with details on the various aspects of the IDR process under the No Surprises Act, enacted as part of the Consolidated Appropriations Act, 2021 (CAA) (see our Checkpoint article). As background, the CAA expanded patient protections to shield individuals from surprise bills for emergency services, air ambulance services furnished by a nonparticipating provider (i.e., an out-of-network provider or other provider that does not have a contractual relationship with the plan), and non-emergency services furnished by a nonparticipating provider at an in-network facility in certain circumstances. Implementing regulations established a federal IDR process for use by out-of-network providers, plans, and insurers to resolve payment disputes after an unsuccessful open negotiation (see our Checkpoint article). Among other things, the regulations require the parties to a dispute to submit their offers for payment, with supporting documentation, to a certified IDR entity, which then issues a binding determination.

This guide includes detailed information on how the parties may initiate the IDR process and describes the requirements of the process, including specifics on the rules that certified IDR entities must follow in making a payment determination. It also includes information related to other aspects of the IDR process, including guidance on confidentiality standards, fees, and recordkeeping and reporting requirements, as well as how parties may request an extension of certain time periods for extenuating circumstances. Useful timelines and tables are provided, including a table with a detailed summary of the IDR process and required notices.

EBIA Comment: Group health plans must implement the complex surprise billing rules for plan years beginning on or after January 1, 2022. Although the process guide is designed to provide guidance to certified IDR entities, it contains practical information for plans and advisors preparing for or involved in the IDR process. The agencies note that additional guidance may be developed in the future to address specific questions or scenarios submitted by certified IDR entities. For more information, see EBIA’s Health Care Reform manual at Section XII.B.3 (“Expanded Patient Protections: 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.

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