Responding to criticism from radiologists, feds aim to fix dispute resolution under No Surprises Act
Responding to criticism from radiology and other specialties, the Biden administration issued a proposed rule on Friday aimed at fixing the dispute-resolution process under the No Surprises Act.
If finalized, the rule would seek to improve communication between health insurers, physicians and the independent entities that arbitrate disagreements over out-of-network payments. The federal government also wants to adjust timelines for the independent dispute resolution (or IDR) process, along with establishing new criteria for “batching” together similar IDR requests. Officials also would seek to change the administrative fee structure, hoping to “improve accessibility of the process.”
Imaging groups such as the Radiology Business Management Association and American College of Radiology—which have lobbied for the feds to improve IDR and make it less slanted in insurers’ favor—said they were still reviewing the rule late Monday.
“Again, the tri departments’ [of Health and Human Services, Labor and Treasury] proposed rules regarding IDR fail to reflect the bias against physicians participating in the fair-to-all process,” RBMA Executive Director Bob Still told Radiology Business. “Regrettably, patients will be the losers. RBMA will be developing more extensive comments regarding the impracticalities of the proposed batching and submission process,” he added.
Federal officials said Friday that they believe the No Surprises Act update will improve timely payment determinations while creating a more efficient IDR process.
“The Biden-Harris administration continues to demonstrate a commitment to implementing the law for the American people,” Centers for Medicare & Medicaid Services Administrator Chiquita Brooks-LaSure said in a Oct. 27 announcement from the agency. “Today’s proposed rule will strengthen the communication between healthcare payers and providers and improve upon the independent dispute resolution process.”
Here is a quick rundown of the proposed changes:
Communication between payers and providers: Responding to industry feedback, the departments are proposing that payers be required to provide additional information at the time of initial payment or notice of denial. The proposed rule also would require insurers to use standardized codes to communicate whether a claim is or is not subject to the NSA’s surprise billing provisions and eligible for the independent dispute resolution process.
Open negotiation and IDR initiation: The departments are proposing several changes to encourage disputing parties to engage in negotiations before initiating IDR. Payers and providers would be required to handle open negotiations via the IDR portal, including providing formal notice of denial of payment to the other party and the federal departments.
“Under the current process, a party must contact the other party directly to initiate open negotiations, which has resulted in uncertainty as to whether open negotiation was ever properly initiated,” CMS noted.
IDR eligibility and administrative fee: The proposed rule also would establish a departmental eligibility review process, which could be invoked when the volume of disputes is high. This way, the departments could provide added support to facilitate faster dispute processing.
“Eligibility determinations for the federal IDR process have proven to be complex, time-consuming, and resource-intensive, and certified IDR entities are often uncompensated for such eligibility work,” CMS said in the announcement.
The departments additionally are proposing that they would begin directly collecting the nonrefundable administrative fee. They also would lay out requirements for when parties should pay this charge and propose consequences for failing to pony up. In addition, the feds are suggesting a reduced fee structure for parties in low-dollar disputes, hoping to promote “equitable access” to initiating the IDR process.
Batching: The administration also is proposing new batching provisions, allowing qualified IDR items and services to be grouped together “in order to address the unique circumstances of certain medical specialties and provider types.” According to a corresponding fact sheet from CMS, this would include radiology, anesthesiology, pathology and laboratory items and services billed under service codes belonging to the same Category I CPT section.
For more on the proposed changes, you can read the CMS press release, corresponding fact sheet, or the entire 443-page proposed rule. The public will have 60 days to submit comments.
Further NSA reading
A few other NSA-related radiology items from the past few days:
- On Oct. 26, the day before the proposed rule was published, the American College of Radiology submitted comments urging the federal government to keep the IDR process affordable for members of the specialty. ACR also emphasized the importance of letting radiologists batch together like claims, allowing for fewer IDR submissions and promoting efficiency in the system. The American Hospital Association also submitted comments on Oct. 26, noting that it opposes proposed fee increases for the IDR process.
- Radiology Partners, the nation’s largest imaging group, shared a blog post on Oct. 27, detailing its recent Hill Day. Members of the practice met with congressional representatives to advocate on behalf of the specialty. “We were discussing some of the challenges associated with the federal No Surprises Act independent dispute resolution process,” breast imaging specialist Sarah Avery, MD, said in the blog post. “I think that’s a really great opportunity for RP to present real data at a national level.”
- Fitch Ratings shared an analysis on Monday, noting that the No Surprises Act is proving more consequential for some U.S. healthcare providers. The agency expects indirect effects of the act to be more significant than foregone revenues, with many impacted providers asserting that they no longer (or never did) engage in such surprise billing practices. ED services (60% of disputed bills by code), radiology (14%) and anesthesia (7%) were the billing codes most frequently submitted to the new IDR process during the quarter that ended Dec. 31, 2022, Fitch noted.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.