Biden Administration Releases Proposed Rule on No Surprises Act IDR Process

On Oct. 27, the departments of Health and Human Services, Labor, and the Treasury released a  proposed rule that would update the federal independent resolution process (IDR) under the No Surprises Act. The IDR process is a mechanism for providers and payers to resolve payment disputes for certain out-of-network charges. The rule would modify the requirements for the open negotiations period between payers and providers preceding the IDR process, establish new criteria for batching, and change the administrative fee structure to improve accessibility of the process.  

To improve pre-dispute discussions, the departments proposed to require plans to include claim adjustment reason codes and remittance advice remark codes and other information with the initial payment or notice of payment denials to communicate whether the payer considered an item or service subject to the No Surprises Act. To initiate an open negotiation, a party would be required to use the federal IDR portal to notify the other parties. The current guidance on batching permits parties to include multiple items or services in a single “batched dispute” if the item or service was billed under the same service code or a comparable code under a different procedural code system. This requirement has been challenged by invested parties as it requires multiple disputes for a single patient encounter.  

In response to these concerns, the departments proposed to allow batching for services that are: furnished to a single patient on one or more consecutive dates of service and billed on the same claim form; services billed under the same service code or a comparable code under a different procedural code system; or anesthesiology, radiology, pathology, and laboratory items and services billed under service codes belonging to the same Category I CPT code section.  

The Centers for Medicare & Medicaid Services published a fact sheet on the proposed rule. Comments on the IDR proposed rule are due by Jan. 2, 2024.