The DOL, IRS, and HHS have issued a course of information for licensed impartial dispute decision (IDR) entities with particulars on the assorted facets of the IDR course of beneath the No Surprises Act, enacted as a part of the Consolidated Appropriations Act, 2021 (CAA) (see our Checkpoint article). As background, the CAA expanded affected person protections to defend people from shock payments for emergency providers, air ambulance providers furnished by a nonparticipating supplier (i.e., an out-of-network supplier or different supplier that doesn’t have a contractual relationship with the plan), and non-emergency providers furnished by a nonparticipating supplier at an in-network facility in sure circumstances. Implementing rules established a federal IDR course of to be used by out-of-network suppliers, plans, and insurers to resolve cost disputes after an unsuccessful open negotiation (see our Checkpoint article). Amongst different issues, the rules require the events to a dispute to submit their affords for cost, with supporting documentation, to a licensed IDR entity, which then points a binding dedication.
This information consists of detailed info on how the events might provoke the IDR course of and describes the necessities of the method, together with specifics on the foundations that licensed IDR entities should observe in making a cost dedication. It additionally consists of info associated to different facets of the IDR course of, together with steerage on confidentiality requirements, charges, and recordkeeping and reporting necessities, in addition to how events might request an extension of sure time durations for extenuating circumstances. Helpful timelines and tables are supplied, together with a desk with an in depth abstract of the IDR course of and required notices.
EBIA Remark: Group well being plans should implement the advanced shock billing guidelines for plan years starting on or after January 1, 2022. Though the method information is designed to offer steerage to licensed IDR entities, it comprises sensible info for plans and advisors making ready for or concerned within the IDR course of. The businesses notice that extra steerage could also be developed sooner or later to handle particular questions or situations submitted by licensed IDR entities. For extra info, see EBIA’s Well being Care Reform handbook at Part XII.B.3 (“Expanded Affected person Protections: Shock Medical Billing (Emergency and Non-Emergency Providers)”). See additionally EBIA’s Group Well being Plan Mandates handbook at Part XIII.B (“Affected person Protections”) and EBIA’s Self-Insured Well being Plans handbook at Part XIII.C (“Federally Mandated Advantages”).
Contributing Editors: EBIA Employees.