As health plans and providers navigate the implications and components of the industry-reforming Consolidated Appropriations Act (CAA), federal agencies recently issued a final rule updating fees for the independent dispute resolution (IDR) process established within the CAA’s No Surprises Act. The IDR process for fully insured groups is managed by the insurer; self-funded plans will rely on their third-party administrator.
The No Surprises Act was designed to shield patients from costly unexpected medical bills for emergency services rendered at out-of-network facilities, and certain services performed by out-of-network doctors at in-network locations. Patients who experience these situations are only liable for the cost they would have incurred in-network unless prior notice and consent were given. If a provider gives a patient prior notice that their service will be billed at a higher out-of-network rate and obtains consent to charge the higher amount, the provider may charge the higher rate.
Providers and insurers can still negotiate reimbursement on their end. When an insurer receives a bill, they generally have 30 days to either pay, adjust or deny payment. After another 30 days, if an insurer and provider cannot agree on a payment amount, the IDR process can be triggered, and a third party will be appointed to arbitrate and determine reimbursement. For disputes initiated between August 3, 2023, and January 21, 2024, the administrative fee per party per dispute is $50. The recently released final rule increases fees for disputes opened on or after January 22, 2024, to $115. The legislation also established that effective January 1, 2024, certified IDR entities can charge between $200 and $840 for single determinations, and between $268 and $1,173 for batched determinations. The administrative fee is shared between both parties, while the IDR fee is paid only by the non-prevailing party.