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No Surprises Act Arbitration Decisions Resume

After revising its guidelines on how certain medical fee disputes should be resolved, the Centers for Medicare & Medicaid Services has directed the Independent Dispute Resolution entities responsible for arbitrating fee disputes between payers and providers to resume making and issuing their decisions.

After a February ruling in federal court that aspects of CMS’s implementation of the 2020 No Surprises Act contradicted the language of the act itself and unfairly favored payers over providers, CMS ordered a moratorium on new arbitration decisions for disputes filed on or after October 25, 2022 while it reviewed and revised its guidance on how those disputes should be decided.  Now, CMS has completed that task and issued new guidance to the Independent Dispute Resolution entities that adjudicate the disputes and to the parties in those disputes.

Go here to see the new CMS guidance to the parties in disputes and here for the guidance to the Independent Dispute Resolution entities.


Some Surprise Billing Dispute Decisions to Resume

The Independent Dispute Resolution entities empowered by the No Surprises Act of 2020 to adjudicate disagreements between providers and payers may resume their work – but only some of it.

According to the Centers for Medicare & Medicaid Services,

On February 24, 2023, certified IDR entities were instructed to resume processing payment determinations on February 27, 2023, for disputes involving items or services furnished before October 25, 2022.

But CMS also announced that

Certified IDR entities will continue to hold issuance of payment determinations that involve items or services furnished on or after October 25, 2022 until the Departments issue further guidance.

The work of IDRs was brought to a halt by a federal court ruling earlier this month that found that the process created by federal agencies to implement the No Surprises Act violated the terms of that law by unduly favoring health care payers over providers.

Learn more about where the dispute resolution process stands and what providers and payers can expect from the federal agencies charged with responsibility for implementing the No Surprises Act from this CMS notice.…

Surprise Billing Law Stumbles in Court

A federal judge in Texas has vacated part of the arbitration process that is a major aspect of the No Surprises Act, the federal law enacted to reduce surprise medical bills.  In the wake of this ruling, the Department of Health and Human Services has directed the entities charged with mediating payment disagreements to stop making decisions.

In the Texas case challenging the fairness of the independent dispute resolution process that is a key component of the surprise billing law’s implementation, the federal judge found that the arbitration process unfairly favored payers over providers, most notably by placing undue emphasis on the qualified payment amount (QPA) that is a major part of the arbitration process.  The decision explains that

The Court first held that the interim rule improperly “places its thumb on the scale for the QPA, requiring arbitrators to presume the correctness of the QPA and then imposing a heightened burden on the remaining statutory factors to overcome the presumption.” 

The judge’s decision also explained that

The interim rule, moreover, characterized the non-QPA factors as “permissible additional factors” that an arbitrator may consider only “when appropriate.”  The interim rule thus conflicted with the Act, which unambiguously requires arbitrators to

Hospitals Improving Electronic Data Exchange

Hospitals are improving their interoperability and doing a better job of exchanging health data electronically, according to a review by the federal Office of the National Coordinator for Health Information Technology (ONC).

According to a new ONC report,

  • In 2021, more than 6 in 10 hospitals engaged in key aspects of electronically sharing health information (send, receive, query) and integrating of summary of care records into EHRs, a 51 percent increase since 2017.
  • Availability and usage of electronic health information received from outside sources at the point of care significantly increased over the last four years, reaching 62 and 71 percent, respectively, in 2021.
  • Health Information Service Providers (HISPs) and HIEs were the most common methods used for electronic exchange among hospitals.
  • About three-quarters of hospitals participate in health information exchange organizations (HIEs) and about 35 percent participate in both HIEs and national networks.
  • In 2021, 39 percent of hospitals reported participating in more than one of four measured national networks.
  • Nearly 90 percent of hospitals upgraded their EHRs to 2015 Edition through 2021 and 74 percent of hospitals adopted bulk data export technology.

Learn more about progress in the federal government’s quest for health data interoperability in the ONC …

States Look to Take on Prior Authorization

The majority of states may act on insurer prior authorization practices in the coming year and even though the year is still only a month old, 16 states are already considering legislation to do so.

The desire to act on prior authorization comes as providers continue to express dismay over delays in insurer review of the courses of treatment they seek to initiate for their patients, with some providers maintaining that those delays are jeopardizing the well-being of those patients.

Insurers, meanwhile, insist that their reviews are necessary to ensure the health of their patients.

In response to such expressed concerns, the Centers for Medicare & Medicaid Services late last year proposed revising some current prior authorization regulations.

Learn more about the prior authorization issue and what might be expected in the coming year from the Axios article “States jump into fight over prior authorization requirements.”…