CMS Releases Guidance on Independent Dispute Resolution Process

CMS has launched a webpage containing resources and guidance regarding the federal independent dispute resolution (IDR) process under the No Surprises Act.

The process helps determine reimbursement rates for out-of-network services when surprise billing occurs. When providers and payers cannot agree on a payment rate, the decision falls to an IDR entity.

The CMS webpage includes resources and best practices for parties initiating an IDR dispute. The agency included two videos that provide an overview of the IDR process for disputing parties and a video that offers a walkthrough of the IDR portal.

CMS launched the online IDR portal in April 2022 to create a space where providers and payers can initiate the IDR process within four days after the 30-day negotiation period.

The webpage also includes a PDF detailing how parties can submit a dispute request through the online portal. The document explains what parties should know before starting the online form and the information they will need to submit,

In addition, CMS improved the portal's functionality by including a button to upload supporting documents during the initiation process. Relevant documentation could consist of copies of initial payment, notice of denial of payment, or notice of open negotiation.

The agency provided a list of common mistakes parties should avoid to ensure their dispute is processed as quickly as possible. Common mistakes include:

• Incorrectly batching cases
• Incorrectly submitting disputes involving bundled qualified IDR items or services
• Failing to use the contact information provided with the initial payment or notice of denial payment
• Failing to include the qualifying payment amount (QPA) provided with the initial payment or notice of denial of payment
• Failing to provide documentation of initiation of open negotiation, if the non-initiating party reports that open negotiation did not occur

The guidance also stressed the importance of having the correct contact information for all involved parties to ensure timely communication.

Parties must also verify and submit administrative fees and certified IDR entity fees. The IDR entities will not review dispute submissions if they do not receive payment, the guidance noted.

A complete dispute initiation should include the QPA for disputed items or services, correct contact information for the non-initiating party, and the claim number of the item or services. Without this information, parties will experience delays in processing, CMS stated.

The agency also released a document that provides technical assistance for IDR entities. Topics include batching and bundling, eligibility for the IDR process, and failure to submit required information.

Shortly after CMS launched its new webpage, the Biden Administration released its final rule on the surprise billing IDR process. The regulation states that IDR entities must consider the QPA and all additional information that a party submits to determine the appropriate reimbursement rate.

The change comes after the provisions in the interim final rule received backlash from provider groups.

The American Hospital Association (AHA) and the American Medical Association (AMA) asserted that the interim final rule went against the policies included in the No Surprises Act and directed IDR entities to weigh the QPA more than other factors.

Prior to the final rule, CMS had updated its surprise billing guidance to require IDR entities to consider other factors besides the QPA, including provider experience and training, market share, and the complexity of delivering the item or service.