Federal regulators recently said they are setting up a renewal process for the organizations that help healthcare providers and healthcare payers resolve No Surprises Act billing disputes.
One part of the new recertification process for the No Surprises Act “independent dispute resolution entities” could involve assessments of IDR entities’ fairness.
See also: Employers demand changes to No Surprises Act arbitration
Something officials may consider when looking at a recertification application is the ability of the IDR entity to “provide rationales for payment determinations meeting regulatory requirements,” according to a new set of answers to frequently asked questions about the IDR entity recertification process.
Application reviewers will also look at an entity’s ability to handle a high volume of dispute assignments quickly and the entity’s ability to handle cases “accurately in accordance with statutory and regulatory timelines,” officials say.
Regulations prohibit the entities from having conflicts of interest, and the application reviewers will look for conflicts of interest, officials said.
If application reviewers find that an applicant meets the minimum recertification standards, the applicant will then go through a five-day public petition period.
Regulators will post a list of the entities seeking recertification each week.
During an applicant’s petition period, “members of the public, providers, facilities, providers of air ambulance services, plans or issuers, and state regulators can petition for the denial of the certification of an IDR entity,” according to regulators’ description of the public petition process.
The federal IDR team that put out the new document includes officials from the U.S. Department of Health and Human Services, the U.S. Department of Labor and the U.S. Treasury Department.
Process gives public a chance to say if an entity can be certified
The public petition process will give employers, insurers and other payers a chance to tell regulators if they think an entity is too unfair to the payers to act as an IDR entity.
The backdrop: Congress created the No Surprises Act system in an effort to respond to concerns about “surprise billing,” or cases in which insured patients receive unexpected bills for balances they must pay.
The system applies to patients with commercial health coverage who receive emergency care at out-of-network hospitals; many patients with commercial coverage who end up seeing out-of-network physicians at in-network hospitals; and patients with commercial coverage who use emergency air transportation services.
Regulators created the IDR entity system to help payers and providers resolve No Surprises Act disputes.
The IDR entities operate a review process that looks to laypeople like arbitration. Whether the process is a form of arbitration has been subject to litigation.
The IDR system came to life in 2022.
Health insurers, sponsors of self-insured employer health plans, the plans’ administrators and payer representatives say the IDR system sides with the providers most of the time and awards the providers payment amounts that are far higher than what the providers could have received through ordinary contracts with the payers’ provider networks.
The Turquoise Health IDR tracking system shows, for example, that the median in-network reimbursement rate for an hour of hospital patient observation time was $86 during one period measured. The median IDR award for that item was $19,985.
New IDR rules: Federal regulators recently posted interim final regulations that are supposed to overhaul the IDR system. Officials appeared to say little directly in the regulation packet about the critics’ belief that the IDR system is unfair to health insurers and the administrators of employers’ self-insured health plans.
Some observers argue that procedural changes included in the new regulations could help reduce the level of actual and perceived bias, by requiring providers and payers to include more information when they take disputes to the IDR system and creating a new process for the providers and payers to try to resolve concerns informally before the IDR entity takes charge.
The IDR entity recertification process: Officials said in the new FAQs document that the entity recertification application reviewers will use the same process and regulatory requirements that they use to certify new IDR entity applicants.
Entities that fail to apply for recertification or are rejected will have to refund any IDR entity fees for disputes that are already in progress.
Entities that are rejected and want to object will have 30 days to request a hearing.
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