Federal officials issued proposed changes to the No Surprises Act's independent dispute resolution process in an Oct. 27 news release. They said those changes, if finalized, will improve communication between payers providers and certified IDR entities, create a more efficient dispute resolution process and change the administrative fee structure to improve accessibility.
Eight things to know:
1. Under the proposal, a party choosing to initiate open negotiations must provide an open notice and a copy of the remittance advice or notice of denial of payment to the other party and the federal departments through the IDR portal. This is a change from the current process, in which a party must contact the other party directly to initiate open negotiations; this has resulted in uncertainty as to whether open negotiations was properly initiated, according to the release.
2. The proposal would require an open negotiation response notice to be furnished by the receiving party by the 15th day of the 30-business-day open negotiation period.
3. In an effort to reduce the number of ineligible disputes, payers would be required to use standardized codes to communicate whether a claim for an item or service furnished by an out-of-network provider or facility is or is not subject to the No Surprises Act's surprise billing provisions and the federal IDR process.
4. The proposal would allow for the following qualified IDR items and services to be batched:
- Those furnished to a single patient on one or more consecutive dates of service and billed on the same claim form (a single patient encounter).
- Those billed under the same service code or a comparable code under a different procedural code system.
- Anesthesiology, radiology, pathology and laboratory items and services billed under service codes belonging to the same Category I CPT code section, as specified in guidance by the departments, to address the circumstances of these medical specialties and provider types.
5. The proposal would limit batched determination to 25 qualified IDR items and services to ensure certified IDR entities can make timely eligibility and payment determinations.
6. Certified IDR entities would be required to determine eligibility within five business days of final certified IDR entity selection. Parties would be required to submit additional information to the certified IDR entity or federal departments within five business days of a request for additional information.
7. The federal departments propose collecting the nonrefundable fee directly from the disputing parties to streamline the collection process. The initiating party would be required to pay the administrative fee within two business days of the date of preliminary certified IDR entity selection, while the non-initiating party would be required to pay within two business days of receiving notice of an eligibility determination.
8. A reduced administrative fee would be charged to both parties when the highest offer made during open negotiations was less than a predetermined threshold. The proposal also calls for the non-initiating party to be charged a reduced administrative fee when the dispute is determined ineligible.
Read more about the proposed rule here.