Federal Government Provides Details on No Surprises Act IDR Process
In late January, the Departments of Health and Human Services, Labor, and Treasury issued process guidance and a set of FAQs regarding the independent dispute resolution (IDR) process required by the No Surprises Act. The No Surprises Act protects individuals from surprise bills for certain emergency and non-emergency services received from out-of-network providers or facilities. The amount a health plan must pay the provider for these services is determined by negotiation between the parties, or if negotiation fails, the IDR process.
The process guidance outlines the steps of the federal IDR process. First, if the health plan and the provider cannot agree on a payment amount within 30 days, either party can initiate the IDR process by submitting a notice to the other party and to the Departments. The parties can either agree on an IDR entity from the list available in the Federal IDR portal or the entity can be randomly selected by the Departments. The parties will then submit their offers, and the IDR entity must make a decision within 30 days.
The guidance also reviews the two types of fees related to the IDR process. The first is an administrative fee of $50 for 2022, which is paid by each of the parties for participating in the Federal IDR process. The second is a certified IDR entity fee. The Departments have established a fee range of $200 to $500 for single determinations and $268 to $670 for batched determinations. IDR entities can set their fees within those ranges, or they may request approval for the Departments to set a fee outside of the range. Each party will pay the full IDR entity fee at the time it provides its offer, and the IDR entity will refund the fee to the prevailing party after the decision. For batched determinations, the party with the most determinations in its favor is considered the prevailing party. If the parties settle the dispute, each party will pay half of the entity fee.
The federal IDR process is still a work in progress. The Federal IDR Portal—which must be used to satisfy certain requirements, including initiation of the federal IDR process, selection of an IDR entity, and the submission of offers—initially launched on January 1, 2022, with limited functionality. The Departments intend to continue to provide information about additional functionalities as they become available.