The Departments of Labor, Treasury, and Health and Human Services (tri-agencies) have issued a long-anticipated No Surprises Act final rule.
The rule updates several key requirements related to the independent dispute resolution (IDR) process in response to the ruling by the U.S. District Court for the Eastern District of Texas. The ruling found that key provisions of the July and October 2021 interim final rule were impermissible under the statute. Among other things, the final rule requires that IDR entities:
- Select the offer that best represents the value of the item or service under dispute after considering the qualifying payment amount (QPA) and all permissible information submitted by the parties
- Consider the QPA and then consider all additional permissible information submitted by each party to determine which offer best reflects the appropriate out-of-network rate
- Evaluate any additional information provided to avoid double counting information that is already accounted for by the QPA or by any of the other information submitted by the parties
The final rule also defines “downcoded” claims and establishes requirements related to what information payers must share with providers in these instances.
Along with the final rule, the tri-agencies published a set of frequently asked questions that address issues, such as applicability of the regulations to no-network and reference-pricing plans; how the QPA must be calculated when a given service may be provided by different specialties; and timeliness for initial payments by payers.
Separately, the Centers for Medicare & Medicaid Services has launched a web page with additional resources and guidance related to the IDR process. The web page includes guidance for parties to a dispute and an overview of the federal portal.