CMS revises its guidance on the independent dispute resolution process

Wednesday, April 27, 2022

Following a court ruling that invalidated HHS’ implementation of the independent dispute resolution (IDR) process of the No Surprises Act, CMS revised its guidance for surprise billing.

When determining reimbursement rates, IDR entities are required to consider both the qualifying payment amount (QPA) and other information submitted by parties or requested by the IDR entity.

According to the guidance, IDR entities must not consider three factors for payment determinations:

  • Usual and customary charges
  • The amount that the provider or facility would have billed without the provisions of the No Surprises Act
  • The payment and reimbursement rate of the services by public payers

CMS also stated that it is not the IDR entity’s role to determine if the QPA was correctly calculated, determine medical necessity, or review the coverage denials.

Editor’s note: Access more NAHRI resources on the No Surprises Act here.