September 07, 2023

Government Resumes Independent Dispute Resolution Eligibility Determinations

In response to provider calls for the No Surprises Act (NSA) federal Independent Dispute Resolution (IDR) process to resume following recent court decisions, the Centers for Medicare and Medicaid Services (CMS) announced on Sept. 5 that IDR entities may proceed with making “eligibility determinations” for disputes submitted on or before Aug. 3. This step simply means that IDR entities may verify that submitted disputes meet the criteria for being eligible for IDR. All other aspects of the federal IDR process operations, including payment determinations, remain suspended.

In the lawsuit filed by the Texas Medical Association (TMA), known as “TMA III”, the court determined that the government was incorrectly permitting insurers to use a faulty methodology when calculating their median in-network rate, also known as the qualifying payment amount (QPA). As a result, new regulations on the QPA calculation and its impact on the IDR process will need to be created to comply with the court decision. As such, IDR entities have been instructed to cease all IDR decisions until further notice.

The IDR process has been suspended for initiation of new claims since the U.S. District Court for the Eastern District of Texas ruled in favor of the TMA, Texas Radiological Society, Houston Radiology Associated and others (dubbed “TMA IV”) that the government’s “fee increase and batching rule” implementing the NSA violated federal law on Aug. 3. The court ruled that the government’s “fee increase and batching rule” implementing the NSA violated federal law.

This week’s CMS announcement stated, “The Departments are currently reviewing the court’s decision and evaluating current IDR processes, templates, and system updates that will be necessary to comply with the court’s order.”

These TMA rulings do not impact the patient protections included in the NSA that the American College of Radiology® (ACR®) advocated for and continues to fully support, nor does it raise patient out-of-pocket costs.

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