Earlier this year, the United States Departments of Health and Human Services, Labor, and the Treasury (the Departments) together with the Office of Personnel Management issued a proposed rule with new requirements for group health plans and health insurance issuers; providers, facilities and providers of air ambulance services; and certified Independent Dispute Resolution (IDR) entities as they relate to the Federal IDR process under the No Surprises Act (NSA).
The proposed rule, if finalized, would aim to facilitate communication between payers, providers, and certified IDR entities; adjust specific timelines and steps of the Federal IDR process; establish new batching provisions; create additional efficiencies; and change the administrative fee structure to improve accessibility.
Improved Communication
One of the goals of the proposed rule is to help facilitate communication between payers, providers, and certified IDR entities. The Departments believe that the “early and critical” exchange of information regarding the initial dispute when a payer sends a provider either an initial payment or a notice of denial of payment in response to a submitted claim that may be subject to the NSA is an important component to the entire process. In that initial exchange, the payer must include important information about the claim to the provider, including the qualifying payment amount (QPA) and contact information for opening the negotiation period, that will help the parties to decide whether they would like to contest the initial payment or notice of denial of payment and assess whether the claim is eligible for the Federal IDR process.
However, payers and providers report challenges with communicating and obtaining key information necessary to resolve payment disputes. Therefore, the Departments propose that payers be required to provide additional information at the time of initial payment or notice of denial of payment, including the legal business name (if any) of the plan or issuer, the legal business name of the plan sponsor (if applicable), and its IDR registration number. It is further proposed that payers include those disclosures in a statement explaining that providers must notify the Departments to initiate open negotiation. The Departments also propose to require payers to share information with providers by using specific claim adjustment reason codes (CARCs) and remittance advice remark codes (RARCs) – to be specified in guidance and distinct from the list of NSA-related RARCs effective March 1, 2022 – when they provide any remittance advice to an entity that does not have a contractual relationship with the payer.
Adjust Timelines
Currently, under the NSA and regulations, there is a 30-business-day open negotiation period for disputing parties to have an opportunity to agree on an appropriate payment rate without having to go through the Federal IDR process. Open negotiation also serves as an opportunity fo disputing parties to exchange information about the items and services in dispute to better understand whether the claim should proceed to the Federal IDR process.
However, the Departments have received reports that the open negotiation process is not often filled with meaningful negotiations. Therefore, the Departments are proposing that a party must provide an open negotiation notice to the other party and the Departments through the Federal IDR portal to begin the open negotiation period. The 30-business-day open negotiation period would begin on the day the party submitted the open negotiation along with a copy of the remittance advice or notice of denial of payment to all parties through the Federal IDR portal.
The proposal also aims to push the open negotiation process along by requiring the open negotiation response notice be furnished by the party in receipt of the open negotiation notice to the other party and the Departments by the 15th business day of the 30-business-day open negotiation period.
Batched Disputes
The proposed rule included new batching provisions as well, which would come into play when qualified IDR items and services relate to a treatment of a similar condition and encourage efficiency (including minimizing costs). The Departments propose allowing batching under the following circumstances: (1) items and services furnished to a single patient on one or more consecutive dates of service and billed on the same claim form (a single patient encounter); (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 guidance by the Departments, in order to address the unique circumstances of these medical specialties and provider types. Batching would be limited to 25 qualified IDR items and services in a single dispute.
Additional Changes and to Submit Comments
For more information on the proposed changes and to review the Federal Register notice, click here. The comment period for the proposed rule ends on January 2, 2024; all comments in response to the proposal would need to be submitted prior to that date.