HHS releases IDR proposed rule

HHS released a proposed rule on October 27 regarding the federal independent dispute resolution (IDR) process for the No Surprises Act. The rule focuses on early communication between payers and providers, the open negotiation period, batching, eligibility, administrative fee structure, and registration.

To ensure that all parties have adequate information to determine IDR eligibility, HHS is proposing that payers be required to provide additional information at the time of initial payment or denial notice, such as the legal business name of the plan or issuer. In addition, the department is proposing that payers must include a statement in these disclosures stating that providers must notify the departments to initiate open negotiation, according to the CMS fact sheet

To improve communication and efficiencies in the federal IDR process, HHS is proposing to require a party to provide an open negotiation notice to the other party and departments through the federal IDR portal to initiate the open negotiation period. The department is also proposing that the open negotiation response notice be furnished by the receiving party to the initiating party by the 15th day of the 30-day period.

HHS is proposing to allow the following qualified IDR items and services to be batched:

• Items and services furnished to a single patient on one or more consecutive dates of service and billed on the same claim form (a single patient encounter)
• Items and services billed under the same service code or a comparable code under a different procedural code system
• Anesthesiology, radiology, pathology, and laboratory items and services billed under service codes belonging to the same Category I CPT code section, as specified by guidance

HHS is also proposing to limit batched determinations to 25 qualified IDR line items in a single dispute to ensure timely eligibility and payment determinations. Along the same line, the department is proposing to require certified IDR entities to determine eligibility within five business days of the final certified IDR entity selection. These entities would then be required to notify both disputing parties and the departments.

To ensure access to the federal IDR process when parties are unable to resolve disputes in open negotiation, HHS is proposing to collect the non-refundable administrative fee itself, directly from the disputing parties, rather than having certified IDR entities collect it on its behalf.

The department is also proposing for the initiating party to be required to pay the administrative fee within two business days of the date of preliminary certified IDR entity selection. If an initiating party fails to pay the administrative fee within that time frame, the dispute would be closed for non-payment, and neither party would owe the administrative fee.

In addition, the non-initiating party would be required to pay within two business days of receiving notice of an eligibility determination, according to HHS. If a non-initiating party does not pay the administrative fee as required, that party’s offer would not be considered received.

Providers have found it difficult to identify payers and retrieve the correct contact information when initiating open negotiation, according to HHS. In response to this, the department is proposing to require eligible payers to register, receive a registration number, and “provide general information on the applicability of the federal IDR process to items or services covered by the plan or coverage.”

Revenue integrity professionals must ensure their organization is in compliance with the No Surprises Act. Review the rule and understand HHS’ proposed changes to the federal IDR process.

Editor's note: Find more NAHRI resources on the No Surprises Act here.