Insights

No Surprises Act Independent Resolution Process Guidance for Disputing Parties


The DOL, IRS and HHS recently released a process guide for certified independent dispute resolution (IDR) entities with detailed guidance on the various aspects of the Federal IDR process under the No Surprises Act (the Act) that took effect on January 1, 2022. The Act was enacted as part of the Consolidated Appropriations Act, 2021 (CAA) passed by Congress in late 2020.

Under the No Surprises Act, providers are prohibited from imposing balance bills for emergency services and air ambulance services provided by out-of-network providers, as well as nonemergency services provided by out-of-network providers at in-network facilities in certain circumstances (e.g., an out-of-network anesthesiology or radiology service provided at an in-network healthcare facility). As an integral part of the Act, the regulations established the Federal IDR process for out-of-network providers, plans and insurers to resolve payment disputes if the parties cannot agree on the payment amount after they attempt to hold an open negotiation.

The guide includes information on how the parties to a payment dispute may initiate the Federal IDR process. Additionally, it describes the detailed requirements of the Federal IDR process, such as the associated fee that the participating parties are responsible for paying and the procedures the certified IDR entities must follow in making a payment determination. Moreover, the guide describes certified IDR entities’ requirements to fulfill confidentiality standards, record keeping requirements and the process for revocation of IDR certification. The guide also explains how parties may request an extension of certain time periods for extenuating circumstances.

(For more information on the Act and the interim final rules, see the articles published in the July 7, 2021, November 9, 2021 and January 19, 2022 editions of Compliance Corner.)

Employers, particularly self-insured plan sponsors, should be aware of the new Federal IDR process.

Federal Independent Dispute Resolution (IDR) Process Guidance for Certified IDR Entities (December 2021) »