The
Centers
for
Medicare
and
Medicaid
Services
finalized
a
new
rule
on
Thursday
to
improve
the
federal
independent
dispute
resolution
(IDR)
process
under
the
No
Surprises
Act.
The
update
is
designed
to
reduce
costs
and
administrative
burden
for
both
providers
and
payers,
the
agency
said.
The
No
Surprises
Act,
which
went
into
effect
in
2022,
seeks
to
protect
Americans
from
unexpected
medical
bills
by
banning
many
forms
of
surprise
billing
for
out-of-network
emergency
care.
It
also
established
a
federal
arbitration
process
for
payer-provider
disagreements
over
out-of-network
payment
amounts.
Both
providers
and
payers
have
expressed
frustrations
with
the
current
IDR
process,
with
complaints
about
high
administrative
fees,
long
delays
and
a
growing
backlog
of
disputes.
CMS
said
there
have
been
more
than
5
million
disputes
since
the
No
Surprises
Act
went
into
effect.
This
is
far
more
than
the
agency
had
expected
—
it
originally
estimated
it
would
be
handling
about
17,000
disputes
per
year.
In
response
to
the
high
volume
of
disputes,
CMS
said
the
new
rule
seeks
to
make
the
IDR
process
more
efficient
and
less
costly
for
all
parties
involved.
One
of
the
biggest
changes
CMS
made
on
Thursday
was
lowering
the
administrative
fee
from
$115
to
$15
per
party
per
dispute.
The
agency
will
also
allow
for
batching
of
certain
eligible
disputes,
which
lets
providers
and
payers
group
similar
claims
together
in
a
single
arbitration
process
when
they
involve
the
same
parties
and
comparable
circumstances.
Additionally,
CMS
finalized
changes
aimed
at
streamlining
how
disputes
enter
the
IDR
system,
including
clearer
eligibility
and
submission
requirements
to
decrease
ineligible
or
duplicative
filings.
By
strengthening
upfront
screening,
cases
are
less
likely
to
stall
on
procedural
issues
once
they
reach
arbitration,
CMS
said.
“We
are
cutting
fees,
improving
transparency
and
restoring
order
to
a
system
that
was
overwhelmed.
This
is
about
making
government
processes
efficient,
accountable
and
focused
on
results,”
CMS
Administrator
Mehmet
Oz
said
in
a
statement.
Provider
groups
have
generally
welcomed
the
news.
For
instance,
the
Federation
of
American
Hospitals
told
MedCity
News
it
supports
the
rule
because
it
believes
the
changes
will
make
the
IDR
process
more
transparent
and
efficient,
while
reinforcing
payers’
responsibilities
during
payment
disputes.
Similarly,
the
Medical
Group
Management
Association
said
CMS’
reforms
are
a
step
in
the
right
direction.
“Cutting
the
administrative
fee
from
$115
to
just
$15
per
party
removes
a
real
barrier
to
access
to
the
IDR
process
—
particularly
for
smaller
practices.
Requiring
health
plans
to
clearly
indicate
whether
a
claim
is
subject
to
IDR
will
bring
greater
transparency
and
help
eliminate
the
costly
problem
of
ineligible
claim
submissions.
We
will
continue
to
analyze
the
full
rule
in
the
days
ahead,
but
MGMA
is
encouraged
by
these
commonsense
reforms,”
said
Anders
Gilberg,
MGMA’s
senior
vice
president
of
government
affairs,
in
a
statement.
Another
healthcare
leader
—
Carol
Skenes,
chief
of
staff
at
Turquoise
Health,
a
healthcare
pricing
and
contract
management
startup
—
noted
that
while
the
new
rule
is
an
improvement,
there
is
still
a
need
for
greater
transparency
around
qualifying
payment
amount
(QPA)
calculations.
These
are
the
median
in-network
rates
payers
use
as
a
benchmark
during
the
IDR
process.
“Ensuring
the
QPA
is
a
trustworthy
rate
alongside
a
more
streamlined
open
negotiation
window
and
IDR
process
both
work
in
tandem
to
help
alleviate
the
dispute
backlog
and
simplify
the
path
to
dispute
resolution,”
Skenes
said
in
a
statement
sent
to
MedCity
News.
The
Coalition
Against
Surprise
Medical
Billing
also
thinks
that
the
IDR
could
still
use
some
additional
work.
The
organization
believes
more
needs
to
be
done
to
eliminate
the
“ongoing
abuse
and
misuse
of
IDR”
by
some
providers.
Industry
groups
representing
employers
and
payers
have
increasingly
raised
concerns
that
some
providers
are
overwhelming
the
IDR
process
by
filing
large
volumes
of
disputes
in
pursuit
of
higher
reimbursement
payments.
“Patients
and
employers
cannot
afford
continued
exploitation
of
the
law’s
IDR
process.
Additional
reforms
are
needed
to
address
the
flood
of
disputes
from
IDR
middlemen
and
the
misaligned
incentives
driving
inflationary
awards
to
a
handful
of
private
equity-backed
providers,”
the
coalition
said
in
a
statement.
The
organization
urged
the
Trump
administration
to
crack
down
on
“persistent
bad
actor
providers
and
IDR
middlemen”
so
that
the
No
Surprises
Act
can
better
deliver
on
its
promise
of
protecting
patients
and
reducing
healthcare
costs.
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