On October 27th, the departments of HHS, Labor, Treasury, and the Office of Personnel Management proposed new requirements related to the Independent Dispute Resolution (IDR) process set up by CMS to dispute out-of-network claims. The proposed rule would adjust timelines and steps of the IDR process, establish new batching provisions and modify the administrative fee structure. While some of the changes are positive, the rule does not adopt many of AHPA’s previous recommendations, including requiring payors to reveal how they calculate the Qualifying Payment Amount (QPA) and imposing financial penalties for payors that don’t reimburse providers on time, as stipulated by previous regulations.

The Departments propose requiring that payors provide additional information at the time of initial payment or notice of denial of payment. Since payers and providers agree that there are obstacles in communicating disputes, the Departments propose a standardized process to ensure all parties possess the necessary information to determine if a payment dispute is eligible for the IDR process. It includes:

  • The legal name of the plan or issuer or plan sponsor, the IDR registration number, and a disclosure from the payer notifying the Departments to initiate open negotiation.
  • Payers would be required to use specific claim adjustment reason codes and remittance advice remark codes when dealing with entities where no contractual relationship exists.

Many open negotiation notices were found not to be eligible for the IDR process, only clogging up the overall process and slowing down resolution for eligible IDRs. Proposed changes to IDR eligibility include:

  • Requiring that parties seeking to initiative negotiations provide an open negotiations “notice” to the other party through the IDR portal. That process starts the clock on the 30-day of the open negotiation period.
  • Specifying that an open negotiation response must be furnished by the 15th business day of the 30 business-day open negotiation period.
  • Setting a five business-day window for certified IDR entities to determine eligibility and notify both parties.
  • Establishing an eligibility review process to support eligibility during delays;
  • Initiating a Department eligibility review when there are extenuating circumstances.
  • Providing public notice by the Departments on when the review process will begin or when the application is terminated.

New batching provisions are also proposed to enhance efficiency and reduce time and cost. Batching is proposed for items and services provided they are:

  • Provided to a single patient on one or more consecutive dates from a single patient encounter;
  • Billed under the same service code or a comparable code under a different procedural code system;
  • Anesthesiology, radiology, pathology, and laboratory items and services billed under service codes belonging to the same Category I CPT code section.

Batch determinations would also be limited to 25 qualified IDR line items in a single dispute.

The proposal also seeks to encourage disputing parties to settle their disputes independently, when possible. To do this, they propose that:

  • Non-refundable administrative fees be collected directly from disputing parties;
  • The initiating party be required to pay the administrative fee within two business days of “preliminary certified IDR entity selection,” and the other party to pay within two business days of the receipt of the notice;
  • Administrative fees not paid on time by the initiating party have their disputes closed for non-payment, with neither party owing the fee;
  • Debt collection procedures be levied against non-initiating parties that fail to pay.

AHPA extends our gratitude to Tequila “Tee” Nelson, guest author of this article.
Tee is a respiratory supervisor and a student in the Master of Healthcare Administration program at Loma Linda University