The Centers for Medicare & Medicaid Services and other federal agencies have finalized a long-awaited rule meant to reduce the number of ineligible payment disputes flowing into the No Surprises Act’s Independent Dispute Resolution (IDR) process.
More than 5 million disputes have entered IDR since it launched in April 2022, far exceeding expectations and creating delays and unnecessary costs, CMS said.
The No Surprises Act established a 30-business-day open negotiation period to give payers and providers a chance to agree on a payment rate without arbitration. But that step has not been working as intended.
“The departments have received numerous reports that the parties are not meaningfully engaging in open negotiation before proceeding with IDR, including reports of open negotiation notices submitted containing vast numbers of items and services, not all of which would ultimately be eligible for the Federal IDR process,” CMS said.
What it does:
- Payers must give providers specific claim adjustment reason codes (CARCs) and remittance advice remark codes (RARCs) to signal whether a claim qualifies for IDR.
- An open negotiation notice must be sent to start the clock, and the 30-business-day period now begins when that notice and the payment remittance or denial are submitted to the other party.
- A new open negotiation response notice is due by the 15th business day of that window.
- Certified IDR entities must determine eligibility within five business days of being selected.
And:
- Batching rules now let parties bundle multiple items or services into a single dispute, capped at 50 line items.
- The administrative fee drops to $15 per party per dispute, regardless of the amount in dispute or eligibility.
- Payers must now register and provide identifying information, receiving an IDR registration number. Providers have long reported difficulty identifying the right payer, especially when distinguishing between group health plans offered by the same sponsor.
For healthcare providers and the agencies that eventually work medical accounts, the takeaway is cleaner, faster determinations earlier in the cycle, before disputed balances harden into collectible debt.
What they said:
