The Centers for Medicare and Medicaid Services (CMS) and the other agencies responsible for implementing the No Surprises Act (NSA) published two updates on the NSA’s Independent Dispute Resolution (IDR) process. The first update describes a new process for resubmitting batched disputes that were originally rejected.

The batching process has been administratively difficult to understand and comply with. Many disputing parties have struggled to properly submit batched disputes. CMS is now creating what it hopes will be a more streamlined process for resubmitting batched disputes after they were rejected.

According to CMS:

“The new resubmission process will be automated in the Federal IDR portal. Resubmission requests will come from the Federal IDR portal instead of from your certified IDR entity, and initiating parties will now have a unique web form they can access via a link in their resubmission email notification to complete the resubmission process.

If a dispute you are a party to is eligible to be resubmitted to the IDR process, you will receive an email notification from auto-reply-federalidrquestions@cms.hhs.gov. If you initiated the dispute, the email notification will contain a unique link to a new form called the Notice of IDR Initiation – Resubmission web form and instructions on the next steps.

Once this change is implemented, initiating parties will continue to have 4 business days from the date of the resubmission email notification to initiate the resubmitted dispute.” CMS will provide additional information and education as this process is developed.

The second update clarifies how a recent court decision on the qualifying payment amount (QPA) calculations will impact beneficiary cost-sharing. That court case successfully challenged how health plans calculate the QPA. For situations protected by the NSA, the patient’s in-network cost-sharing benefit will apply for the out-of-network (OON) charges. More specifically, the OON provider can only charge the patient the lesser of either the QPA or the billed charge. Since the court case means the QPA calculations were wrong, providers were wondering if they had to recalculate the cost-sharing amount and re-bill patients.

Similarly, many health plans submitted the QPA as their amount in the IDR process. The court case suggests that there was an error with these determinations because the health plan submission was inaccurately calculated.

CMS has already been using its enforcement discretion to essentially accept the original QPA calculation that was used for these purposes despite the court’s decision that the calculation formula was incorrect.  A new FAQ from CMS clarifies that CMS and the other agencies responsible for implementing the NSA will continue to exercise enforcement discretion for items and services furnished before November 1, 2024.

This will give health plans additional time they need to recalculate their QPA amounts.

ADVOCATE will share additional information with clients and friends as it becomes available on this and other Federal Health Policies.

Kirk Reinitz, President