October 12, 2023

Federal Government Resumes Independent Dispute Resolution for Single Claims

ACR Decries Continued Pause of Batched IDR Claim Processing

The Centers for Medicare and Medicaid Services (CMS) announced Oct. 6 that the portal for providers and insurers to file payment disagreements related to the No Surprises Act (NSA) is again open for the initiation of new single claim disputes. CMS temporarily suspended the independent dispute resolution (IDR) process Aug. 3, following the U.S. District Court for the Eastern District of Texas’ decision in the lawsuit known as Texas Medical Association (TMA) IV; that decision vacated regulations related to batching provisions and the administrative fee that must be paid to file a disputed claim.

The IDR portal notably remains unavailable, however, for providers who wish to submit multiple claims in a batch, and previously submitted batched claims remain on hold.

The American College of Radiology® (ACR®) strongly opposes the continued pause of the IDR process for batched claims, as many imaging claims eligible for dispute are less than the current $50 administrative fee required to be paid to initiate the process.

The guidance by the U.S. Departments of Health Human Services, Labor, and Treasury, and the U.S. Office of Personnel Management on the reopening of the IDR process for single claims also includes detailed information about extensions of deadlines to initiate the IDR process. If the initiation deadline for a claim is between Aug. 3 and Nov. 3, parties have until Nov. 3 to initiate a new dispute.

Federal Government Disagrees With Court in Disputed Claims Calculation Ruling, Intends Appeal

In a separate decision in the case known as TMA III, the court determined that the government incorrectly permitted insurers to use a faulty methodology when calculating their median in-network rate, also known as the qualifying payment amount (QPA).

The federal government in separate guidance addressed the TMA III decision to vacate regulations related to the QPA calculation methodology. The departments state that they disagree with this decision and the Department of Justice intends to appeal. While the government recognized that the court decision remains in effect during the appeal process, the departments state that insurers are required to calculate QPAs “in a manner consistent with the statutes and regulations that remain in effect.” The government did not provide specific instructions to insurers on a new calculation methodology, but rather indicated that they are “expected to calculate QPAs using a good faith, reasonable interpretation of the applicable statutes and regulations.” In addition, the departments state that they will “exercise their enforcement discretion” for insurers that continue to use QPAs calculated under the now vacated guidance for at least the next six months and possibly until Nov. 1, 2024. The departments also encouraged states that operate IDR processes under their own laws to similarly use enforcement discretion with regard to QPAs.

The ACR is also disappointed in the absence of QPA recalculation guidance, and the government’s intention to allow insurers to continue to use QPAs calculated using the now vacated methodology. The College continues to monitor whether and how the government decides to enforce a federal court’s decision.

The TMA rulings do not impact the patient protections included in the NSA that the ACR advocated for and continues to fully support, nor do they raise patient out-of-pocket costs.

For more information or if you have questions, contact Katie Keysor, ACR Senior Director of Economic Policy.