The Centers for Medicare and Medicaid Services (CMS) recently launched its Independent Dispute Resolution (IDR) Portal for providers and insurers to settle payment disputes as required by the No Surprises Act (NSA). The availability of the IDR process was delayed due to a court ruling in Texas that the insurer-provider payment arbitration process in the federal Surprise Billing Interim Final Rule issued last fall violates the Administrative Procedure Act. Along with the announcement of the IDR process availability, CMS also issued guidance for both the IDR entities and the disputing parties (i.e., insurers and providers).
The federal government has until April 25 to file an appeal of the Texas ruling. In the meantime, CMS has rescinded the portions of the Interim Final Rule that directed the IDR entities to consider the qualified payment amount (QPA), or median in-network payment rate as calculated by insurers, as the primary determining factor in the IDR process. This portion of the rule ignored the law’s intent that the QPA be among equally weighted factors considered in these disputes. The informal IDR guidance instructs the entities to consider both the QPA and “additional credible information” submitted by the disputing parties, with no mention of the QPA being the primary determining factor. CMS is expected to release a formal Final Rule on the process by early summer.
The American College of Radiology® (ACR®), American College of Emergency Physicians and American Society of Anesthesiologists are also suing agencies of the federal government to block the IDR parts of the rule implementing the NSA. However, the ACR lawsuit leaves the patient protections intact. Currently, the ACR lawsuit is on hold because the court issued a stay until May 3, while the government decides whether to appeal the Texas case.