The long and winding history of federal regulations and court rulings connected with the No Surprises Act continues to grow with every passing month it seems. The latest NSA rules are discussed in today’s alert.
There are some things that we’ve just come to expect: a paycheck at regular intervals, power outages that seemingly occur with every storm and the daily (if not hourly) mess made by a busy toddler. Expectations serve a purpose. They psychologically prepare us for what is sure to come—whether good or bad.
For those trying to get a handle on the rules connected with federal No Surprises Act (NSA), it sure seems as if there is something new every month or so—whether that involves a federal court ruling, a process pause or a revised regulation. It’s something we’ve come to expect. So, what is the latest and greatest when it comes to rules and rulings surrounding the NSA? The following will provide a brief overview.
Opening the Portal
No, we’re not talking about opening a portal to the fifth dimension or stepping through a doorway in time. Such sci-fi vortices seem rather tame in comparison to the back-and-forth jolts to which the healthcare community has been recently subjected relative to the independent dispute resolution (IDR) portal and overall process.
This past December 15, those federal departments empowered to promulgate regulations with respect to the NSA—specifically Health and Human Services (HHS), Treasury and Labor (hereinafter jointly referred to as “the Departments”)—reopened the Federal IDR portal for all dispute types. You will recall that it is through this electronic portal that providers may initiate a request for a federally certified IDR mediator when there is a dispute over the reimbursement amount involving a medical service where the provider does not participate with the patient’s insurance plan.
Over the last several months, there has been a series of announcements by the Departments relative to the IDR portal being opened, then paused, then open again, then closed, etc. The December 15 action by the Departments that reopens the portal includes the addressing of previously initiated batched disputes, new batched disputes, and new single disputes involving air ambulance services.
According to the December 15th announcement:
The Federal IDR process protects consumers against out-of-network balance billing by providing a process whereby providers (including air ambulance providers), facilities, and health plans can resolve payment disputes for certain out-of-network charges. Since August 2023, parts of the portal to submit Federal IDR disputes were closed due to recent court orders and opinions. The portal is now fully operational.
So, unless something has transpired between December 15 and the writing of this article, anesthesia providers can fully avail themselves of the IDR portal. “But,” you interject, “isn’t there a cost to accessing this process?” Funny you should ask.
Paying the Piper
On December 18, 2023, the Departments issued a final rule on IDR administrative fee and certified IDR entity fee ranges. A fact sheet was published by the Centers for Medicare and Medicaid Services (CMS) summarizing the major elements of the final rule.
The rule specifically finalizes an administrative fee of $115 per party for disputes initiated on or after the effective date of the rule. The CMS fact sheet goes on to state the following:
For disputes initiated on or after the effective date of this rule, the Departments are finalizing a certified IDR entity fee range of $200-$840 for single determinations and $268-$1,173 for batched determinations. Further, for batched determinations exceeding 25 dispute line items, the Departments are finalizing the proposal that certified IDR entities may set a fixed fee within the range of $75-$250 for each increment of 25 dispute line items included in the batched dispute, beginning with the 26th line item. The Departments are finalizing the proposal that the certified IDR entity fee ranges will remain in effect until the Departments propose and finalize different certified IDR entity fee ranges in subsequent notice and comment rulemaking.
The final rule provides that the administrative fee amount will be established no more frequently than once per calendar year. This is in response to comments requesting more stability in the administrative fee amount.
So, it remains up to each provider to determine if the cost of disputing an insurance payment is worth the fee, effort and potential frustration. The American Society of Anesthesiologists has recently stated that it is generally pleased that the Departments are allowing the batching of disputed claims as part of the IDR process. The question is, will this be enough to convince anesthesia providers to brave the portal?
Should you have any questions, please reach out to your account executive.