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What Is Shock Billing IDR?


QUESTION: We’ve heard that group well being plan claims for sure companies have to be resolved below federal IDR guidelines. What’s IDR, and what claims does it apply to?

ANSWER: The No Surprises Act (included within the Consolidated Appropriations Act, 2021 (CAA)) protects people from shock payments for sure out-of-network companies (see our Checkpoint article), and establishes an unbiased dispute decision (IDR) course of below which out-of-network suppliers and well being plans could resolve disputes over claims topic to the regulation. (For extra details about the shock billing protections, see our Checkpoint Query of the Week.) The necessities apply to emergency objects and companies offered in a hospital emergency division (together with an outpatient division that gives emergency companies) or in an unbiased, freestanding emergency division geographically distinct and licensed individually from a hospital below state regulation. The foundations additionally apply to non-emergency objects or companies 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) at an in-network facility, in addition to to out-of-network air ambulance companies, i.e., medical transport of sufferers by helicopter or airplane.

The IDR course of could also be initiated by out-of-network suppliers, plans, and insurers solely after an unsuccessful “open negotiation” (see our Checkpoint article). Suppliers and plans have a 30-day interval, starting on the day the supplier receives an preliminary cost or denial discover from the plan, to provoke open negotiations and decide an agreed quantity for cost. If the open negotiations don’t lead to an agreed cost quantity, the supplier or plan could pay the required charges and provoke an IDR course of by way of the HHS IDR Portal. The method permits the disputing events to submit their cost gives and supporting documentation to an authorized IDR entity, which then points a binding willpower. This federal IDR course of entails paper evaluation, with out hearings, and the licensed IDR entity should make its willpower of the cost quantity for a certified IDR merchandise or service no later than 30 days after the date the entity is chosen.

For extra info, see EBIA’s Well being Care Reform guide at Part XII.B.3 (“Shock Medical Billing: Emergency and Non-Emergency Providers”). See additionally EBIA’s Group Well being Plan Mandates guide at Part XIII.B (“Affected person Protections”) and EBIA’s Self-Insured Well being Plans guide at Part XIII.C (“Federally Mandated Advantages”).

Contributing Editors: EBIA Workers.

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