March 02, 2023

Independent Dispute Resolution Entities Resume Payment Determinations for Some Payment Disputes

The Centers for Medicare and Medicaid Services (CMS) announced Feb. 24 that certified independent dispute resolution (IDR) entities will resume making payment determinations for payment disputes under the No Surprises Act (NSA) for applicable out-of-network items or services furnished before Oct. 25, as of Feb. 27. A temporary hold was placed on all IDR payment determinations Feb. 6, due to a court decision in favor of the Texas Medical Association (TMA). This decision vacated provisions of the NSA regulations that instructed IDR entities to consider the qualifying payment amount (QPA) the primary factor when determining appropriate out-of-network provider reimbursement rates.

The CMS notice indicates that certified IDR entities will continue to hold payment determinations for disputes involving items or services furnished on or after Oct. 25 pending further guidance. The notice states, “The Departments are working diligently to complete necessary guidance and system updates in order to allow certified IDR entities to resume processing payment determinations for disputes furnished on or after October 25, 2022.”

In a joint letter sent to CMS on Feb. 28 by the American College of Radiology®(ACR®), American Society of Anesthesiologists and the American College of Emergency Physicians, the organizations urged the expedited resumption of all IDR payment determinations, including those for items or services furnished on or after Oct. 25. The letter states that delays in payment determinations are exacerbating the existing IDR backlogs and harming members’ practices by holding up payments for services provided to patients.

It is important to note that the hold only applies to the payment determinations by the IDR entities and all other timelines for the IDR process continue to apply. Providers should continue to engage in open negotiations with payers and IDR process submissions, including offers and the associated fees as usual.

ACR supported the TMA’s lawsuit by filing an amicus brief in October. Two additional lawsuits have been filed by the TMA addressing the QPA calculation methodology and the 600% administrative fee increase for the IDR process announced in December. The College filed an amicus brief on the QPA lawsuit in late January and the administrative fee increase lawsuit in February.

For more information, contact Katie Keysor, ACR Senior Director, Economic Policy.