The Centers for Medicare & Medicaid Services (CMS) and Department of Health and Human Services (HHS) recently released a variety of resources related to the No Surprises Act.
Updated Independent Dispute Resolution (IDR) Administrative Fees: Given the larger –than-anticipated volume of claims submitted to the federal IDR process, HHS is increasing the IDR administrative fee. The fee due from each party for participating in the federal IDR process will increase from $50 set forth in the prior 2023 guidance to $350 for disputes initiated during the calendar year that began Jan. 1, 2023. The updated fee guidance is available on CMS’ website.
Updated FAQs: On Dec. 27, 2022, CMS released updated FAQs that include guidance on the following topics:
- How can federally qualified health centers and other providers and facilities that offer sliding fee discounts comply with good faith estimate (GFE) requirements?
- How can providers comply with the GFE requirements if they do not expect to bill uninsured/self-pay individuals for scheduled/requested items or services?
- When would an abbreviated GFE be subject to the patient-provider dispute resolution process, and how would that process apply?
- What types of contact information should providers and facilities include in a GFE for uninsured/self-pay individuals?
Initial Report on Federal IDR Process: HHS issued its initial report on the federal IDR process, covering the period April 15 to Sept. 30, 2022. During that time, out of 90,078 disputes, the majority were for emergency and non-emergency services (84%) submitted by health care providers, while 15% of disputes were submitted by health care facilities.
Of the 90,078 disputes, 1,359 were initiated by California hospitals or providers for emergency and non-emergency services.
The remaining disputes were submitted by group health plans, health insurance issuers, or federal employees’ health benefits carriers (<1%). Non-initiating parties challenged the eligibility of nearly half (40,517) of the disputes that were filed during this time period. Of the 11,316 disputes that were closed by Sept. 30, 2022, and were challenged as ineligible by the non-initiating party, 9,031 disputes (80%) were ultimately found ineligible for the federal IDR process.