Businesses Launch FAQs and One other Course of Information About Shock Billing Impartial Dispute Decision

The DOL, IRS, and HHS have collectively issued FAQs and course of steerage for disputing events to handle the unbiased dispute decision (IDR) course of beneath the No Surprises Act, enacted as a part of the Consolidated Appropriations Act, 2021 (CAA) (see our Checkpoint article). As background, the CAA expanded affected person protections to protect people from shock payments for sure emergency and non-emergency companies. Implementing rules established a federal IDR course of to be used by out-of-network suppliers, plans, and insurers to resolve fee disputes after an unsuccessful open negotiation (see our Checkpoint article). Amongst different issues, the rules require the disputing events to submit their presents for fee, with supporting documentation, to a licensed IDR entity, which then points a binding willpower. This newest steerage offers particulars on the IDR course of. Listed here are highlights:

• Licensed IDR Entities. A number of of the Q/As tackle data particular to the {qualifications} and software course of for licensed IDR entities (e.g., licensing, accreditations, and conflicts of curiosity). Q/A-10 advises {that a} record of licensed IDR entities is out there on the HHS web site and might be up to date on a rolling foundation.
• Charges. In Q/As-19 and -20, the businesses describe the 2 permitted forms of IDR charges. An administrative payment (set at $50 for 2022) is paid by every of the disputing events for taking part within the federal IDR course of, and a licensed IDR entity payment (starting from $200 to $500 for single determinations and $268 to $670 for batched determinations) is about by the entity beneath company payment steerage. Q/A-21 explains that every occasion pays the whole licensed IDR entity payment on the time it offers its provide, and the licensed IDR entity refunds the prevailing occasion’s payment inside 30 enterprise days after making a willpower. Every of the disputing events pays half the licensed IDR entity payment if a case is settled, except the events agree in any other case.
• Course of. The businesses verify in Q/A-28 that the federal IDR course of entails paper evaluate, permitting the events to submit supporting paperwork along with these required beneath the IDR course of, however with out hearings. The FAQs emphasize that the federal IDR course of doesn’t exchange the exterior claims evaluate course of, which addresses adversarial profit determinations involving enrolled people moderately than fee disputes involving suppliers or amenities. Different Q/As tackle the interaction between IDR and state and federal exterior evaluate fashions. And Q/A-39 offers a hyperlink to a state-by-state record detailing every state’s IDR guidelines. As well as, the businesses have launched a course of information for disputing events which has similarities to a not too long ago launched course of information for licensed IDR entities (see our Checkpoint article) however targeted on the federal IDR portal and course of data for the events searching for to resolve claims. The information contains an outline of the federal IDR course of with a timeline and abstract of the steps, and offers hyperlinks to sources comparable to mannequin required notices.

EBIA Remark: The federal IDR portal launched with functionalities associated to uninsured people on January 1, 2022. Functionalities for suppliers, amenities, plans, and insurers are anticipated to be out there “within the coming weeks.” The businesses estimate that there might be roughly 17,000 IDR requests yearly. Plans and insurers ought to familiarize themselves with the IDR course of necessities for disputing events—notably since some timeframes for motion are fairly brief. For extra data, see EBIA’s Well being Care Reform handbook at Part XII.B.3 (“Shock Medical Billing: (Emergency and Non-Emergency Providers”). See additionally EBIA’s Group Well being Plan Mandates handbook at Part XIII.B (“Affected person Protections”) and EBIA’s Self-Insured Well being Plans handbook at Part XIII.C (“Federally Mandated Advantages”).

Contributing Editors: EBIA Workers.