Surprise Billing Proposals Aim to Streamline IDR Process

The Biden-Harris Administration has released a proposed rule to improve the independent dispute resolution (IDR) process for surprise billing by addressing payer-provider communication and adjusting open negotiation policies.

The No Surprises Act established a 30-business-day open negotiation period to allow disputing parties to agree on a payment rate without using the federal IDR process.

To improve communication between payers and providers during the open negotiation period, the Departments of Health and Human Services, Labor, and the Treasury (the Departments) have proposed to require that a party provide an open negotiation notice to the other party through the federal IDR portal to initiate the period. The party receiving the open negotiation notice must respond by the 15th business day of the 30-day period.

Payers must also use standardized codes to communicate whether a claim for an item or service furnished by an out-of-network provider is subject to the No Surprises Act’s surprise billing provisions and the IDR process.

The Departments proposed to include new content elements in the open negotiation notice, including plan type, location of service, and claim number, according to a fact sheet.

The rule also proposed changes to the batching provisions, which dictate how parties can include multiple items or services as separate payment determinations in a single dispute. The Departments would allow the following qualified IDR items and services to be batched:

• items and services furnished to a single patient on one or more consecutive dates of service and billed on the same claim form
• items and services 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

The proposed batching adjustments aim to encourage efficiency and minimize costs within the IDR process without impeding payers’ or providers’ access to the process.

The rule also addresses eligibility determinations, which have been complex, time-consuming, and resource-intensive, leading to delays in processing disputes. The Departments propose to require certified IDR entities to determine eligibility within five business days of IDR entity selection. They also propose establishing an eligibility review process to support determinations during a period of system delay or other extenuating circumstances.

The rule would streamline the collection of administrative fees for the IDR process by having the Departments collect the non-refundable fees directly from the disputing parties instead of certified IDR entities collecting the fees. In addition, the initiating party must pay the administrative fee within two business days of the date of certified IDR entity selection, while the other party must pay within two business days of receiving notice of an eligibility determination.

The policies in the proposed rule aim to streamline the federal IDR process for payers and providers, reduce the administrative burden that accompanies the process, and continue to protect patients from unfair medical billing.