“No Surprises Act” Internal Dispute Resolution System is Now Live

Article by: Brandy Boone, General Counsel, Medical Association of the State of Alabama

The Centers for Medicare and Medicaid Services (CMS) announced on April 15, 2022, that their Internal Dispute Resolution (IDR) portal for determining reimbursement for services covered under the No Surprises Act is now available. The opening of the portal was delayed because of a federal district court ruling that struck down part of the interim final rule related to billing under the No Surprises Act.  Because of this delay, CMS cautioned in its announcement that there may be a backlog in handling IDR cases.  Therefore, the deadline for initiating the IDR process for parties whose open negotiation time period expired before the portal was available has been extended to May 6, 2022.  Also, CMS has indicated that requests for extensions will be granted as appropriate.

The No Surprises Act’s prohibitions on balance billing for out-of-network hospital, ambulatory surgical center (ASC) and air ambulance services went into effect January 1, 2022.  The IDR process was established to determine appropriate compensation for these out-of-network providers.  Once a provider receives a denial or initial payment from a health plan for out-of-network services, the provider and plan have a 30-day open negotiation period to determine appropriate reimbursement.  If that period ends without resolution of the billing dispute, the provider must initiate the IDR process within four business days of the end of the open negotiation period.  However, as mentioned above, for any open negotiation periods ending before the portal went live, providers have 15 days to initiate the IDR process through the IDR portal.

Providers who wish to begin the IDR process may do so here: https://www.cms.gov/nosurprises/help-resolve-payment-disputes/payment-disputes-between-providers-and-health-plans.  CMS suggests having the following information available when initiating the IDR process:  (1) Information to identify the IDR items, (2) dates and locations of services or items in dispute, (3) Type of items or services (e.g., emergency services), (4) Applicable codes for services and place of services, (5) Attestation that services or items in dispute are within scope of the IDR process, and (5) the preferred IDR entity (IDR entities make the actual determination of reimbursement for services and must be mutually agreed upon by the parties in dispute.) CMS also provides a list of certified IDR entities: https://www.cms.gov/nosurprises/Help-resolve-payment-disputes/certified-IDRE-list.

The provisions of the No Surprises Act that became effective January 1, 2022, also included a requirement for healthcare facilities to provide a good faith estimate to uninsured or self-pay patients prior to the rendering of those services. If patients entitled to receive this good faith estimate get a bill after the services are rendered that is more than $400 in excess of the good faith estimate, they can initiate the provider-patient dispute resolution (PPDR) process to determine appropriate reimbursement.  The PPDR is similar to the IDR, in that an entity agreed upon by the parties, called a Select Dispute Resolution (SDR) entity makes the actual reimbursement decision.  Patients may use CMS’ IDR portal to begin the PPDR process, and they have 120 days following the receipt of a bill that is more than $400 higher than the good faith estimate to do so.