IDR Update: Revised CMS Guidance Ends Hold on Payment Determinations with Fair and Balanced Approach

By: Cristina N. Hyde, JD

On March 17, 2023, the federal government issued updated guidance regarding the independent dispute resolution process (IDR) under the No Surprises Act (the “Act”).  The purpose of the updated guidance is to align the Act’s implementing regulations more closely to the plain language of the law.

The Act provides federal protections against balance billing, shielding patients from receiving unexpected, and often exorbitant, out-of-network medical bills.  However, it’s implementing regulations have been under fire as unfairly favoring insurers over providers.  Challengers argued that the August 2022 Final Rule required that undue weight be placed on the qualifying payment amounts (QPA) and median in-network rates, requiring arbiters to presume their correctness when determining payments.

Earlier this year, the United States District Court for the Eastern District of Texas arrived at the same conclusion; causing a halt on related payments until the challenged portion of the rule could be revised.  On February 6, 2023, after hearing arguments in the matter of Texas Medical Association, et al. v. United States Department of Health and Human Servicesthe Court agreed with providers’ concerns that the August 2022 Final Rule implementing the Act improperly restricted an arbitrator’s discretion and created an unlawful bias in favor of the QPA when making price decisions.  Therefore, the judge ordered that the challenged provisions be vacated and reconsidered.

Approximately one month later, on March 17, 2023, new guidance was issued instructing IDR entities to take a more balanced approach to making payment determinations.  Specifically, the new guidance requires that IDR entities consider all information submitted by both parties without weighing one factor (such as QPA) more heavily than the others.

With the publication of the new guidance, CMS has announced the resumption of the IDR process.  Additional information, including useful fact sheets and forms relating to IDR and the Act, can be found on the United States Centers for Medicare & Medicaid website.

Our Principal Attorney has hosted two free webinars relating to the No Surprises Act which can be found on the Campanella Law Office YouTube channel:

If you have questions about the No Surprises Act and how it affects you or your health care facility and payment procedures, contact us.

Comments are closed.