CMS recently released a progress report updating the public on the No Surprises Act’s (NSA) long-awaited Advanced Explanation of Benefits (AEOB) and Good Faith Estimate (GFE) requirements. The AEOB and GFE requirements were both supposed to go in effect January 1st, 2022, but CMS deferred enforcement. CMS also released NSA Independent Dispute Resolution (IDR) data from January 1st through June 30th, 2023. The data shows that an overwhelming majority of determinations broke in favor of the provider.

Background

In addition to holding patients harmless from surprise bills, the NSA requires the provision of GFEs to patients. Those GFEs are supposed to contain cost information from every provider involved in a patient’s care for any scheduled services and apply to both insured and uninsured individuals. To date, CMS has only required a GFE for uninsured and self-pay patients since there is currently no mechanism for providers of different organizations to exchange cost information with each other and with payors. The report states, “Although industry has made progress in this area, more work is needed before implementing a nationwide, standards-based exchange of this information.”

More Details Coming…But Not Anytime Soon

The most recent Unified Agenda indicated the proposed rule would be out in March, however, the April 23rd progress report suggests the regulation is far from imminent. The Digital Services at CMS (DSAC) recommended a single data exchange standard for the receipt and transmission of the GFE and AEOB data. To date, DSAC has not been able to identify any current standards and the report suggests that the Agency may conduct a pilot first, which would take time. “While technical standards for insured GFE and AEOB implementation are still being developed, a potential real-world pilot or demonstration project of these standards may provide meaningful feedback for future iterations of data exchange standards,” the report states.

Details on the IDR Data

CMS released data covering the nearly 84,000 disputes that certified IDR entities decided. Providers or facilities prevailed in 77% of the payment determinations, and most of the winning offers (82%) were higher than the Qualified Payment Amount (QPA). The Brookings Institution released a report in which they noted that IDR decisions also greatly exceeded Medicare rates and prior in-network commercial market prices.