The Centers for Medicare and Medicaid Services issued revised guidance for the federal independent dispute resolution (IDR) process that is part of the No Surprises Act. The new guidance is the direct result of the federal litigation filed by the Texas Medical Association that was decided in favor of physicians. On March 17, certified IDR entities were instructed to resume making payment determinations and that they must consider all information submitted to determine the appropriate out of network rate (that is otherwise not prohibited).

Congress passed the No Surprises Act in December 2020. As legislation evolved, the CAP worked with federal lawmakers and other physician organizations to drastically improve this policy.

Certified IDR entities have now resumed processing all payment determinations after a delay issued by the Department of Health and Human Services (HHS) and other departments. In addition, the HHS and other departments have completed the necessary updates to the federal IDR portal and federal IDR process guidance documents to reflect these revised payment determination standards.

In both the March 2023 IDR Guidance for Disputing Parties and the March 2023 Federal IDR Process Guidance for Certified IDR Entities, the Departments specify that the IDR entities must consider that qualifying payment amount (QPA)(s) for the applicable year for the qualified IDR item or service, and other information submitted by a party as long as it does not contain prohibited factors. This removes the flawed “double counting” specification or other weight to the QPA. Also, starting March 17, disputing parties will begin receiving most of their payment determination notices from the IDR portal, specifically from auto-reply-ederalidrquestions@cms.hhs.gov.

This development does not address the CAP’s other issues with the implementation of the federal IDR process, including abuse of the open negotiation process, the volume of IDR cases, batching, and the incredibly high non-refundable administrative fee. The CAP continues to engage with Congress and federal agencies to ensure an accessible and equitable system for resolving payment disputes.

Check out the CAP’s No Surprises Act resources.