December 16, 2021
The Federal No Surprises Act, which seeks to reduce unexpected medical bills for patients, is taking effect as plans renew January 1, 2022. It brings many new regulations for health plans and providers, including new rules for a federal independent dispute
resolution (IDR) process.
Here’s a brief overview to help you understand the dispute resolution rules and how we’ll be implementing them.
How it works
The IDR process is for health plans and providers, facilities, and air ambulance providers to follow for certain out-of-network claims when open negotiations don’t result in an agreed-upon payment amount. It will be entered into by both parties and overseen
by certified, independent entities.
All parties will be required to meet deadlines, attest to no conflicts of interest, choose certified independent dispute resolution entities, submit payment offers, and provide additional information if needed.
Federal IDR portal
For claims subject to the federal No Surprises Act, the IDR process will be managed through a dedicated Federal IDR online portal. (Claims covered by WA law will continue to go through the existing state process.) The federal portal will handle all aspects
of the process, including notification, entity selection, documentation submission, and decision communication.
The following are some key aspects of how the online portal will work:
- Batched items and services may be submitted and considered jointly as part of one payment determination by a certified IDR. Claims may be batched together in one of two ways: (1) by batching claims for same or similar services between the same provider
or facility and health plan within the same 30-business day period or (2) if the multiple claims are part of bundled payment where the health plan makes or denies an initial payment.
- IDR Entities must presume that the qualifying payment amount (QPA) is the appropriate out of network payment amount and choose the offer that is closest to the QPA. They’re allowed to consider a limited number of additional factors (e.g., provider
experience, provider market share, patient acuity, contracting efforts) when deciding if the QPA is not the appropriate amount.
- Fees for the IDR entity will be within a range set by the government and will be submitted to the entity at the beginning of the process. Upon conclusion, the IDR entity will remit the winner’s payment. There is also an administrative fee that both
parties will pay for participation.
Additional information about the portal will become available over the next several months, including information about how to initiate an independent dispute resolution process in the federal portal.
Timeline
| Independent Dispute Resolution Action |
Timeline |
| Initiate 30-business-day open negotiation period |
30 business days, starting on the day of initial payment or notice of denial of payment |
| Initiate independent dispute resolution process following failed open negotiation |
4 business days, starting the business day after the open negotiation period ends |
| Mutual agreement on certified independent dispute resolutions entity selection |
3 business days after the independent dispute resolution date |
| Departments select certified independent dispute resolution entity in the case of no conflict-free selection by parties |
6 business days after the independent dispute resolution date |
| Submit payment offers and additional information to certified independent dispute resolution entity |
10 business days after the date certified independent dispute resolution entity selection |
| Payment determination made |
30 business days after the date certified independent dispute resolution entity selection |
| Payment submitted to the applicable party |
30 business days after the payment determination |
Learn More
You can read the No Surprises Act rules, view the model notices, and review the CMS fact sheet for more detail.
We’ll be communicating more about the No Surprises Act in future issues of Provider News. Here are resources are available: