New briefcase icon
After an IDR entity is selected, the parties must submit to the IDR Entity their respective offers for payment of the rate along with supporting documentation.
![new briefcase icon new briefcase icon](https://static.vecteezy.com/system/resources/thumbnails/001/263/411/small_2x/brown-business-briefcase.jpg)
The Interim Final Rule provides that if the parties cannot jointly select an IDR Entity that does not have a conflict of interest, the Departments will select an IDR Entity for the parties. Once the parties initiate the IDR Process, they may jointly select a certified independent dispute resolution entity (“IDR Entity”) to resolve the dispute. Upon the expiration of an unsuccessful open negotiation period, either party may initiate the IDR Process. As part of the No Surprises Act framework for determining the applicable out-of-network rate, the disputing parties must engage in a 30-day open negotiation period, commencing on starting on the day of initial payment or notice of denial of payment, to try to mutually agree on a payment rate before they may initiate and utilize the IDR Process. The Interim Final Rule establishes the formal IDR Process that out-of-network providers, facilities, providers of air ambulance services, and health plans may use to determine the out-of-network rate for items or services to which the No Surprises Act’s surprise billing prohibitions apply if the parties have not mutually agreed upon a rate during a mandatory open negotiation period. This happens most frequently when patients receive medical care from a provider or facility who, unbeknownst the patient, is not in the patient’s health plan’s network (e.g., when a patient urgently goes to the nearest emergency room without any consideration for health plan status). With respect to the IDR Process, the stated goal of the Interim Final Rule is to help take consumers with job-based or individual health plans out of the middle of surprise bill payment disagreements and provide a process for providers, facilities, providers of air ambulance services, and health plans to negotiate out-of-network payments.Ī surprise bill, as contemplated in the No Surprises Act arises when a patient unexpectedly receives a bill for the balance between an out-of-network providers’ billed charges and the amount covered by the patient’s health plan. The specific focus of this article is on the new rules under the No Surprises Act related to the independent dispute resolution process between providers and payors (the “IDR Process”). For a comprehensive summary of all of the new provisions under the Interim Final Rule, as well the Departments’ prior rulemaking under the No Surprises Act, we recommend referencing the Centers for Medicare and Medicaid Services website’s detailed press release regarding the Interim Final Rule: “Requirements Related to Surprise Billing Part II Interim Final Rule with Comment Period” (the “Press Release”). Specifically, the Interim Final Rule establishes provisions related to the independent dispute resolution process, good faith estimates from healthcare providers and facilities for uninsured and self-pay individuals, a patient-provider dispute resolution process, and expanded rights to external review of payors’ claims and coverage determinations. On September 30, 2021, the Department of Health and Human Services, the Department of Labor, and the Department of the Treasury (collectively, the “Departments”) released an interim final rule with comment period entitled “ Requirements Related to Surprise Billing Part II” (the “Interim Final Rule”) relating to Title of Division BB of the Consolidated Appropriations Act of 2021 (the “No Surprises Act”).įor a general introduction to the No Surprises Act, see Nexsen Pruet attorney Matthew Roberts’s article, “Trend Toward Transparency in Pricing Continues.”īuilding on prior rulemaking from the Departments in their Jrule (entitled “ Requirements Related to Surprise Billing Part I”), the Interim Final Rule continues the implementation of the No Surprises Act by providing for additional regulatory requirements under the No Surprises Act.