The Department for Health and Human Services (HHS) is making changes requested by the CAP to the independent dispute resolution (IDR) process for settling out-of-network billing disagreements between physicians and health insurers. The CAP had advocated for significant improvements to the IDR process so to reduce barriers for pathologists to participate.

The CAP had repeatedly expressed to the HHS and Congress a number of concerns about pathologists accessing and appropriately navigating the current IDR system. On October 27, the HHS and other federal departments involved in the IDR system released a proposed rule on the No Surprises Act’s federal IDR process that addressed several of the CAP’s concerns. The CAP had said pathologists needed flexibility for batching claims together as well as reduced fees for low-dollar disputes—both of which have been added to the proposed rule. Additional changes include:

• Accessing Information: The CAP advocated for as much information as possible upfront for the initial payment, or notice of denial of payment, in order to ensure physicians have the necessary insurer-held information to decide about negotiation and to successfully initiate IDR, if needed. The government is now proposing payers be required to provide additional information at the time of initial payment or notice of denial of payment.
• Open Negotiation: The CAP asked to formalize or centralize the open negotiation period to ensure notice is provided and the timeline requirements are successfully met. The government is now proposing to centralize the open negotiation process by requiring that a party choosing to initiate open negotiation give notice through the federal IDR portal.
• Batching: The CAP advocated for flexibility that facilitates broader batching of qualified IDR items and services. The government is now proposing under some circumstances to allow multiple qualified IDR items and services that treat a similar condition to be batched together in a single payment determination proceeding to encourage efficiency and result in cost savings for disputing parties. Pathology and laboratory services fall into this category.
• Administrative Fees: The CAP has said it is vital that any fee requirements take into consideration low-dollar claims and ensure an even and fair playing field for all IDR parties. The CAP urged HHS to waive the administrative fee for low-dollar claims, defined as $250 or under. Alternatively, the CAP would support a tiered fee based on the amount of the claim. The government is now proposing a reduced administrative fee structure and amounts for parties in low-dollar disputes to promote equitable access to initiate the federal IDR process. For amounts less than the amount of the standard administrative fee ($150), the fee will be 50% of the administrative fee, anticipated to be $75.