By Jason Greenberg, MD
In response to the feedback and challenges expressed by several professional medical organizations, the Federal Administration, through the Departments of HHS, Labor and the Treasury (the Departments) released a proposed rule aimed at improving many aspects of the Independent Dispute Resolution (IDR) operations under the No Surprises Act (NSA).
This following provides a detail break down of the nuances of the proposal so you can better understand how it may impact the claims process:
1. Communication and Information Exchange Between Payers and Providers
The Departments proposed mandating additional information at the time of initial payment or denial of payment, most notably:
- Claim adjustment reason codes (CARCs) and remittance advice remark codes (RARCs) to allow non-par providers to determine whether a claim is subject to the No Surprises Act’s surprise billing provisions and eligible for the Federal IDR process.
2. Open Negotiation
The Departments propose that the open negotiation response notice be furnished by the party in receipt of the open negotiation notice to the other party and the Departments by the 15th business day of the 30-business-day open negotiation period.
These proposed changes would create more certainty regarding whether and when an open negotiation period occurred by ensuring that start and end dates are documented in the Federal IDR portal. Additionally, these proposed changes may reduce the number of ineligible disputes initiated by requiring the exchange of eligibility information through the open negotiation notice and the open negotiation response notice.
The Departments propose to limit batched determinations to 25 qualified IDR items and services to optimize timely eligibility and payment determinations and 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,
- Anesthesiology, radiology, pathology, and laboratory items and services billed under service codes belonging to the same Category I CPT code section to address the unique circumstances of these medical specialties.
4. IDR Eligibility
The key cause of delays in processing disputes has been the complexity of establishing eligibility for the Federal IDR process. To support timely eligibility determinations, conflict of interest reviews, and payment determinations, the Departments propose:
- To require certified IDR entities (IDREs) to determine eligibility within five business days of final certified IDRE selection,
- To require additional information to be submitted to the IDRE or the Departments within five business days of the request for additional information.
- To establish Departmental eligibility review process to support eligibility determinations during a period of systemic delay or other extenuating circumstances to facilitate effective processing of disputes under the Federal IDR process.
5. Administrative Fee
The Departments propose to collect the non-refundable administrative fee directly from the disputing parties rather than having the certified IDR entities collect the administrative fee on the Departments’ behalf.
To reduce the need for future administrative fee increases the Departments propose to require:
- The initiating party to pay the fee within two business days of the date of preliminary certified IDR entity selection.
- The non-initiating party to pay within two business days of receiving notice of an eligibility determination.
- If an initiating party fails to pay the fee, the dispute would be closed for non-payment, and neither party would owe the administrative fee.
- If a non-initiating party does not pay the fee as required, that party’s offer will not be considered received.
- Debt collection procedures if a non-initiating party fails to pay the fee in a timely manner.
- Charging a reduced administrative fee to both parties when the highest offer made is less than a predetermined threshold.
- Charging the non-initiating party a reduced fee when the dispute is determined ineligible.
- To determine administrative fee amounts associated with these proposals.
6. Extenuating Circumstances
The Departments propose to amend the extenuating circumstances include events such as an unforeseen volume of disputes or Federal IDR portal system failures and to post a public notice regarding any extensions.
7. IDR Registry
The Departments propose to require payers to register with the Departments and provide general information on the applicability of the Federal IDR process to items or services covered by the plan or coverage. The plan would receive an IDR registration number to make it easier to determine whether the dispute is eligible for the Federal IDR process.
More details and references
Here are some good sources for more details and analysis around this latest development:
- No Surprises Act Independent Dispute Resolution Process Proposed Rule Fact Sheet
- Proposed Rule – Federal IDR Process
- Biden-Harris Administration Advances Efforts to Improve the Surprise Billing Payment Dispute Process
- Feds float No Surprises Act changes
- Responding to criticism from radiologists, feds aim to fix dispute resolution under No Surprises Act
What’s next and how Ventra Health can help
The proposed initiatives are encouraging steps towards a more fully optimized the IDR process. If finalized and executed successfully, we anticipate it would lead the way for more positive developments next year. In the meantime, we are ensuring that Ventra Health is well positioned to expeditiously adopt upcoming process changes to fast forward our clients’ accumulating disputes.
Connect with us
We want to hear from you! Please share with us your thoughts on NSA, TMA III and how this update will impact your operations. You can reach out anytime to ClientEngagement@VentraHealth.com.
Dr. Jason Greenberg is Ventra Health's Chief Client Officer. Dr. Greenberg's subject matter expertise is in anesthesia operations and practice management. Prior to his role at Ventra Health, he was President and CEO of Anesthesia Care Associates Medical Group, a large independent anesthesia medical practice located in San Francisco, CA. He has also served as the President/CEO of Northern California Anesthesia Physicians, and in several clinical leadership roles in the Sutter Health System. Dr. Greenberg serves on multiple committees at the American Society of Anesthesiology, including the Committee for Practice Management, and is on the Perioperative Advisory Board of GE HealthCare. He is also a practicing cardiothoracic anesthesiologist.