IDRs to resume certain payment determinations under No Surprises Act
Effective Feb. 27, certified independent dispute resolution entities will resume issuing payment determinations for payment disputes involving out-of-network services and items furnished before Oct. 25, 2022, the Centers for Medicare & Medicaid Services announced. CMS has posted guidance for certified IDRs issuing payment determinations for items and services furnished before Oct. 25, 2022.
“The standards governing a certified IDR entity’s consideration of information when making payment determinations in these disputes are provided in the October 2021 interim final rules, as revised by the opinions and orders of the U.S. District Court for the Eastern District of Texas in Texas Medical Association, et al. v. United States Department of Health and Human Services, Case No. 6:21-cv-425 (February 23, 2022) (TMA I), and LifeNet, Inc. v. United States Department of Health and Human Services, Case No. 6:22-cv-162 (July 26, 2022) (LifeNet I),” CMS said.
The agency said IDRs will hold issuance of payment determinations for items or services furnished on or after Oct. 25, 2022 until the departments of Health and Human Services, Labor, and the Treasury issue further guidance.
Following a court decision that vacated nationwide the federal government’s revised IDR process, CMS on Feb. 10 instructed certified IDR entities to hold all payment determinations until the departments issued further guidance.
A Texas judge on Feb. 6 held that the revised IDR process skews the arbitration results in commercial insurers’ favor in violation of the compromise Congress reached in the Act. As a result of this decision, the regulations are vacated nationwide.