CMS issues revised guidance for independent dispute resolution process

Photo: Alex Wong/Getty Images

The Centers for Medicare and Medicaid Services has issued revised guidance for the independent dispute resolution (IDR) process that is part of the No Surprises Act implementation.

Certified IDR entities have now resumed processing all payment determinations, after a delay issued by the Department of Health and Human Services and other departments following a February 6 court order.

On March 17, certified IDR entities were instructed to resume making payment determinations for disputes involving items or services furnished on or after October 25, 2022.

The standards governing a certified IDR entity's consideration of information when making payment determinations are provided in the August 2022 final rules, as revised by the opinion and order of the U.S. District Court for the Eastern District of Texas in Texas Medical Association, CMS said.

As of March 17, the Department of Health and Human Services and other departments have completed the necessary updates to the Federal IDR portal and Federal IDR process guidance documents to reflect these revised payment determination standards.

Also starting March 17, disputing parties will begin receiving a majority of their payment determination notices from the IDR portal, specifically from auto-reply-federalidrquestions@cms.hhs.gov.

WHY THIS MATTERS

Jeffrey Davis, director of regulatory and external affairs at the American College of Emergency Physicians, said, "We are pleased that CMS is taking steps to address some of the significant concerns expressed by ACEP and the physician community regarding NSA implementation and that the guidance now more closely reflects the No Surprises Act statute. This is a major step forward that reflects ACEP efforts to make the arbitration process more fair and balanced. However, significant reform is still needed to make sure the IDR process is accessible to physicians, especially those in smaller independent practices. Hopefully, with the IDR process reopened, arbiters can start working through the significant backlog."

THE LARGER TREND

In December 2021, the American Hospital Association, the American Medical Association and others sued HHS and other federal agencies over implementation of the No Surprises Act, saying the process favored rates set by insurers.

The groups were not against the legislation, they said in the lawsuit, but took issue with how HHS implemented the Internal Dispute Resolution process to resolve payment rates between provider and payer. The interim final rule stipulated that the arbitrator must select the offer closest to the Qualifying Payment Amount, which is set by the insurer.

The Texas Medical Association also challenged implementation of the interim rules issued in October 2021. In December 2022, the Texas Medical Association filed its third lawsuit against the No Surprises Act.

On February 6, the U.S. District Court for the Eastern District of Texas issued a judgment and order in Texas Medical Association, et al., v. United States Department of Health and Human Services. As a result of the decision, the departments said they would evaluate and update federal IDR process guidance, systems and related documents to make them consistent with the court decision. 

Effective immediately, certified IDR entities should not issue new payment determinations until receiving further guidance from the Departments and certified IDR entities also should recall any payment determinations, CMS said.

Twitter: @SusanJMorse
Email the writer: SMorse@himss.org  

Dr. Vin Gupta will offer more detail during his HIMSS23 session "Keynote: Healthcare Disruption: Accelerated Opportunities for Care Delivery Alternatives." It is scheduled for Wednesday, April 19, at 8:30 a.m. - 9:30 a.m. CT at the West Building, Level 3, in the Skyline Ballroom, room W375.