Fees set in independent dispute resolution process for providers and payers

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In a final rule on fees for disputed claims, Health and Human Services and other departments are finalizing an amount of $115 per party for disputes initiated on or after the effective date of this rule on Jan. 1, 2024. 

The departments are also finalizing a certified IDR entity fee range of $200-$840 for single determinations and $268-$1,173 for batched determinations. 

Further, for batched determinations exceeding 25 dispute line items, the departments are finalizing the proposal that certified IDR entities may set a fixed fee within the range of $75-$250 for each increment of 25 dispute line items included in the batched dispute, beginning with the 26th line item. 

These fees will remain in effect until the departments propose and finalize a different amount in subsequent notice and comment rulemaking, according to the final rule.

WHY THIS MATTERS

The Federal Independent Dispute Resolution Process has been controversial as providers wait for payment on backlogged claims and raise concerns that the payment amount calculation favors insurers.

A proposed rule released in October requires payers to provide additional information at the time of initial payment or notice of denial of payment. 
The proposal aims to increase clarity and speed up the Federal Independent Dispute Resolution process, which has been backlogged by claims. 
  
The IDR is part of the No Surprises Act Dispute Resolution process, which was enacted as part of the Consolidated Appropriations Act, 2021.

The Administrative Fee and Certified IDR Entity Fee Ranges final rule released by the Departments of Health and Human Services, Labor and the Treasury ensures that when plans and issuers and providers, facilities and providers of air ambulance services cannot agree on an appropriate payment amount for out-of-network items and services, they may enter into the Federal IDR process to determine the appropriate payment amount.
 
Due of an August court decision in the Texas Medical Association, et al. v. U.S. Department of Health and Human Services, portions of the previous guidance that the departments used to establish the administrative fee amount were vacated. 

Because of this, the administrative fee is being established in notice and comment rulemaking, rather than in guidance published annually, according to the Centers for Medicare and Medicaid Services.

THE LARGER TREND

As required by law, both parties to a dispute must pay a non-refundable administrative fee for participating in the Federal IDR process. The amount of the fees paid in a year is estimated to be equal to the amount of expenditures estimated to be made by the departments in a year in carrying out the IDR process. 

The administrative fee amount is based on a methodology that divides the departments' estimated expenditures by the estimated total number of administrative fees paid in the year.
 
The final rule also provides that the administrative fee amount will be established no more frequently than once per calendar year, in response to comments requesting more stability in the administrative fee amount.
 
The rule is open for public comment on www.regulations.gov until Jan. 2, 2024.

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