US Agencies Publish Regulations on Independent Dispute Resolution Process and No Surprises Act Good Faith Estimate Requirements | Knowledge

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Supplier-insurer IDR process

The NSA has called on departments to issue regulations implementing the law’s IDR process for supplier-pay disputes over off-grid reimbursement rates by December 27, 2021. The interim final rule reflects the IDR time limits set out in law. Health care providers may, within 30 days of receiving an upfront payment or a payout notice from the payor, enter into negotiations with the payor to determine an appropriate payment amount. If the negotiations do not result in an agreed payment amount, then at the end of the 30 day period, either party to the negotiations has four days to initiate the IDR process. The initiating party must notify the initiation to the other party and the appropriate federal agency through a unified federal IDR portal. The initiating party must also provide a notice of the certified IDR entity that the party prefers.

The party receiving the notification of the opening of the IDR has three working days to object to the selected IDR entity and offer an alternative. If the parties do not agree on an IDR entity within three days, the HHS Secretary will select one. Within 10 days of selecting the certified IDR entity, the healthcare provider and payer must submit three categories of information, which guide the IDR entity’s decision:

  • An offer for the amount of the off-grid payment, expressed both as a dollar amount and as a corresponding percentage of the Qualifying Payment Amount (QPA), which is typically the payer’s median contractual rate for that item or service provided by the same or a supplier in the same geographical area;
  • Information relating to this offer, as requested by the IDR entity; and
  • Some additional information related to the type of health care provider and payer involved.

The parties may also submit any additional information relevant to the party’s offer, including information relating to “additional circumstances” specified by law: (1) the level of training, experience and quality of the supplier of health care, (2) the market share of the health care provider, (3) the acuity of the person receiving the item or service, or the complexity of providing such item or service, (4) the educational status, the combination of cases and extent of services provided in the facility, and (5) demonstrations of good faith efforts (or lack thereof) made by the health care provider and the plan or the issuer to enter into network agreements during the last four years of the plan.

Reflecting the law, the interim final rule also prohibits the IDR entity from considering three factors: (1) the usual and customary charges for the service or item, (2) the “amount that would have been charged” by the health care provider if the balance billing provisions did not apply and (3) the rate for the service or item payable by a public payer.

Unless the parties to the IDR process agree on a payment amount before the IDR entity makes its decision – in which case that payment amount controls – the IDR entity must, within 30 days of selecting the IDR entity, determine the amount of payment by selecting one of the offers.

To make its decision, the provisional final rule requires the IDR entity to select the offer closest to the QPA unless the entity determines that “credible information submitted by either party. . . clearly demonstrates that the qualifying payment amount is materially different from the appropriate off-grid rate, or the offers are also far from the qualifying payment amount, but in opposite directions. In such cases, the IDR entity should select the offer that the entity believes best represents the value of the item or service, which could be the offer from either of the parts.

The unsuccessful bidder must pay the IDR fees predetermined by the IDR entity. IDR certified entities must charge a rate of between $ 200 and $ 500 (updated annually through guidelines), unless departments approve a higher spread, a system that worsens the financial hardship for the party. loser. Both parties are also required to pay a non-refundable administrative fee set by ministries each year through referral.

Good faith estimates

An interim final rule also establishes requirements for the provision of good faith estimates of expected charges for uninsured or self-paying patients. The HHS announced guidance on August 20, 2021, however, that the HHS will postpone the application of the requirement that healthcare providers provide good faith estimate information to people who are enrolled in a health insurance plan or coverage and seeking to submit a claim to their payers. The HHS has recognized that, given the complexity of developing the technical infrastructure for transmitting the necessary data from healthcare providers to plans and issuers, meeting this requirement to provide good faith estimates to individuals registered or covered is unlikely to be possible by January 1, 2022.

A good faith estimate is a notice of expected charges for a scheduled or requested item or service, including items or services that can reasonably be expected to be provided in conjunction with such items or services. . Health care providers should (1) inquire about and determine if the person is uninsured or is paying themselves, (2) informing the uninsured or who pays themselves an estimate of good faith is available, and (3) provide a good faith estimate to the uninsured person. or a self-paid person. Likewise, if a good faith estimate is requested, the health care provider must determine if the person is uninsured or if they are considering paying out of pocket for the services. If this is the case, then the health care provider must issue a good faith estimate. A good faith estimate issued to an uninsured person must include:

  • Certain identifying information about the patient;
  • Information about the items and / or services that can be reasonably expected to be provided;
  • Information about the health care provider; and
  • Disclaimers stating (1) that the good faith estimate provided is only an estimate, (2) information about the individual’s rights to challenge the fees actually charged if they significantly exceed the good faith estimate, and (3) the estimate is not a contract and does not require the person to obtain the items or services.

Healthcare providers and establishments other than the primary provider / establishment (referred to as the “organizer”) “who provide[] items or services that are usually provided in conjunction with a primary item or service ‘also have an obligation to provide good faith estimate information. These providers and facilities, known as co-providers and co-facilities, must also submit good faith estimate information to the organizing provider / facility, who will then provide this information to the patient. Recognizing, however, that “it may take time” for health care providers “to develop systems and processes to receive and deliver the required information from co-providers and co-facilities”, HHS will exercise, from 1 January to December 31, 2022, the discretion to execute when a good faith estimate provided to an uninsured or self-paid person does not include charges expected from co-providers or co-facilities.

Patient-provider dispute resolution process

A patient may initiate the patient-provider dispute resolution process if the total fee charged by the health care provider is “substantially greater” than the total expected fee shown in the good faith estimate, or “substantially greater than” ”Means an amount that is at least $ 400 more than the total amount of the expenses initially planned. The patient has 120 calendar days from receipt of the initial invoice to initiate the dispute resolution process by submitting a notification to HHS, which chooses a selected dispute resolution entity (SDR) to resolve the dispute. While the process is ongoing, the health care provider should not seek to collect additional amounts from the patient. If the parties reach an agreement on the amount of payment before the date on which a determination by the entity is to be made, the dispute resolution process ends.

If the fees charged are higher than the good faith estimate, corn the SDR entity determines that the healthcare provider does not present any credible information that the difference between the fees charged and the good faith estimate arises from unforeseen circumstances that could not have been reasonably anticipated, the SDR entity must then determine that the amount payable is the good faith estimate. If, however, the charge is greater than the good faith estimate and the SDR entity determines that the provider or facility Is present credible information indicating that the difference between the charge and the good faith estimate is based on unforeseen circumstances that could not have been reasonably anticipated, the SDR entity shall determine that the amount payable is the lesser of:

  • The fees charged; Where
  • The payment amount paid by a plan or issuer for the same or a similar service by the same or a similar supplier in the geographic area where the service is provided.

At the start of the dispute resolution process, the uninsured person must pay the SDR entity an administrative fee. The SDR entity must remit these charges to HHS upon receipt of an invoice from HHS. If the uninsured person wins, the health care provider must pay the person the administrative costs in the form of a reduction in the payment amount determined by the SDR entity.


1 The No Surprises Act was promulgated on December 27, 2020, as part of the Consolidated Appropriations Act of 2020. See Pub. L. 116-2610.


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