More?
It just keeps coming…clarification of the IDR Process, that is. If you’ve read any of our (no less than!) six previous blogposts about the IDR Process, you’d have sympathy for why additional clarification is warranted.
What’s the IDR Process? It stands for the Independent Dispute Resolution Process, and it’s the means by which Plans and Providers must now work out their payment disputes (as applied to federal regulatory issues, that is), thanks to the Consolidated Appropriations Act’s (CAA) No Surprises Act (NSA) requirement. The goal? Remove participants from the melee over how much and who pays for certain Plan services. For a handy chart to determine when the federal application applies, access this CMS Guide.
That’s a lot of acronyms…I feel you.
Breakdown
The CAA of 2021 included a subsection, the NSA, requiring Plans to be more “transparent” regarding billing for services, specifically that for certain services, the element of “surprise” would be eliminated. No more outlandish bills from the five doctors who treated you at the ER after the ski accident while on holiday.
What’s New?
The Departments have now issued a four page Federal IDR Checklist for Plans (after having received numerous complaints). The goal of this checklist, per The Departments:
This checklist is intended to help plans and issuers understand their obligations and comply with key
requirements of the No Surprises Act when processing claims for items and services that fall within the
scope of the new surprise billing protections for emergency services, non-emergency services
performed by nonparticipating providers at participating health care facilities, and air ambulance
services furnished by nonparticipating providers of air ambulance services(“qualified IDR item(s) or
service(s).”
What’s it Mean for Plans?
Review the applicable No Surprises Act Provision and Plan requirements below. Note that though insurers and TPAs will likely handle the dispute process details, Plans retain fiduciary liability. They must oversee Plan providers, including asking questions about their ability to comply with the NSA regulations, and verifying contract language is updated for maximum protection of the Plan and its participants.
| Plans must pay the “recognized amount” for emergency services and certain non-emergency services provided by out-of-network facilities and providers, including air ambulance services. A provider may disagree with the “recognized amount” and initiate a negotiation process followed by submission to an Independent Dispute Resolution (IDR) process. |
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Determination of the recognized amount can be complicated and may require complicated computer processing of large amounts of data. |