On October 25, 2023, PYA Principal Martie Ross and Senior Manager Kathy Reep addressed new proposed rules for the No Surprises Act, including changes to the rules around administrative fees. They also took a deep dive into new guidance that has been published by the agencies with regard to the No Surprises Act.
This update was emailed to webinar registrants after the rules had been released. PYA felt it was important to share this timely news.
Following Up—No Surprises Act Proposed Rule Summary
As promised during PYA’s October 25 webinar on the No Surprises Act (“NSA”), we are providing a summary of the Departments of Health & Human Services, Labor, and Treasury and the Office of Personnel Management (“the Departments”) proposed rule to overhaul the NSA’s independent dispute resolution (“IDR”) process, which was released on October 27. The proposed rule will be published in the Federal Register on November 3. Comments are due January 2, 2024.
CMS will be hosting a Special Open Door Forum on the proposed rule on Thursday, November 2, 2023, at 1:00 PM-2:00 PM ET. You can register for this event here. If you are unable to attend, the recording and transcript will be available here several days after the event.
The proposed rule focuses on “ensuring the timely rendering of payment determinations and to address feedback from interested parties and certified IDR entities to improve the functioning of the Federal IDR process.” Specifically, the Departments propose several changes intended to reduce delays in the IDR process relating to eligibility determinations.
- Each plan and issuer subject to the federal IDR process must obtain an IDR registration number by submitting to the Department’s specified information on the applicability of the federal IDR process to items or services covered by the plan or coverage.
Claim Submission and Processing
- In addition to current requirements, payers must also provide the legal business name of the plan or issuer, the legal business name of the plan sponsor, and its IDR registration number at the time of initial payment or notice of denial of payment.
- Payers must use specific claim adjustment reason codes (CARCs) and remittance advice remark codes (RARCs), to be specified in guidance, when they provide any remittance advice to a facility or provider with which the payer does not have a contract. These CARCs and RARCs will indicate whether a claim for an item or service furnished by an out-of-network provider or facility is subject to the NSA’s surprise billing provisions and eligible for the federal IDR process.
Open Negotiation Period
- The party initiating the open negotiation period must provide to the other party and the Departments through the federal IDR portal an open negotiation notice and copy of remittance advice or notice of denial of payment.
- The 30-business-day open negotiation period will begin on the date the initiating party makes the aforementioned submission.
- The non-initiating party must submit its open negotiation response notice to the other party and the Departments by the 15th business day of the 30-business-day open negotiation period.
- The notice of IDR initiation will be expanded to include additional information relevant to eligibility determinations.
- Within 3 business days of receipt of the notice of IDR initiation, the non-initiating party must submit the notice of IDR initiation response form, indicating whether the federal IDR process applies to the item(s) or service(s) and agreeing or objecting to initiating party’s preferred certified IDR entity (“CIDRE”).
- CIDREs must determine eligibility within five business days of final CIDRE selection and notify both parties and the Departments.
- Parties must submit additional information to the CIDRE or the Departments within five business days of any request for additional information.
- A Departmental eligibility review process will be created to complete eligibility determinations when dispute volume is high.
- The Departments will collect the non-refundable administrative fee directly from the parties rather than having the CIDREs collect the fees on the Departments’ behalf.
- The initiating party must pay the administrative fee within two business days of the date of the preliminary CIDRE selection. The non-initiating party must pay within two business days of receiving notice of an eligibility determination.
- If an initiating party fails to make timely payment of the administrative fee, the dispute will be closed for non-payment, and neither party will owe the administrative fee.
- If a non-initiating party fails to pay the fee, that party’s offer will not be considered received. The Departments will establish debt collection procedures for non-initiating parties that fail to pay administrative fees.
- A reduced administrative fee will be charged when the highest offer made during open negotiation by either party is less than a predetermined threshold.
- A reduced administrative fee will be charged to the non-initiating party when the dispute is determined ineligible by either the CIDRE or the Departments.
- The following items and services may be batched into a single dispute: (1) items and services furnished to a single patient on one or more consecutive dates of service and billed on the same claim form; (2) items and services billed under the same service code (or a comparable code under a different procedural code system); and (3) anesthesiology, radiology, pathology, and laboratory items and services billed under service codes belonging to the same Category I CPT code section, as specified in Departmental guidance.
- No more than 25 items or services may be batched in a single dispute.
This webinar is part of PYA’s twice-monthly “Healthcare Regulatory Roundup” series in which experts from across the firm provide practical insights on the latest regulatory developments.
If you would like assistance with anything related to the No Surprises Act, regulatory impacts, or any matter involving compliance, valuation, or strategy and transactions, one of our executive contacts would be happy to assist. You may email them below or call (800) 270-9629.