The Department of Labor (DOL), the Internal Revenue Service (IRS), and the Department of Health and Human Services (HHS) have released Frequently Asked Questions Regarding the Federal Independent Dispute Resolution Process (FAQs). This new guidance relates to the No Surprises Act, which Congress enacted in 2021 as part of the Consolidated Appropriations Act (CAA).
The three federal agencies issued Federal Independent Dispute Resolution (IDR) Process Guidance for Certified IDR Entities on February 11, 2022, but they rescinded this guidance on February 28, 2022. Likewise, the agencies also released another process guide for parties to payment disputes in January 2022 entitled Federal Independent Dispute Resolution (IDR) Process Guidance for Disputing Parties, but links to the webpage where this guide formerly was located now produce an error page. This is due to revisions made necessary by the court decision in Texas Med. Assoc. v. HHS, 2022 WL 542879 (E.D. Tex. 2022).
The No Surprises Act was designed to protect patients from “surprise” medical bills from some emergency and non-emergency services. The regulations establish a federal IDR process for out-of-network providers, plans, and insurers to resolve payments disputes if negotiations fail to resolve them. Essentially, the parties to the dispute must submit their offers for payment to a certified IDR entity, which then makes a decision binding on the parties. The latest guidance and FAQs provide additional details on the IDR process.
Certified IDR Entities
Beginning January 1, 2022, when parties have a payment dispute that falls under the No Surprises Act, they can choose a certified IDR entity from a list found on the HHS website. HHS will continue to add more IDR entities to the list as they become certified. Entities began applying for certification back in September 2021, and entities can continue to apply for certification on a rolling basis.
Fees
The IDR process involves two different types of fees. First, each party must pay an administrative IDR fee. In 2022, the administrative fee is $50. Each entity also sets a certified entity fee under agency fee guidance. For 2022, this fee is from $200 to $500 for single determinations and $268 to $670 for batched determinations.
Each party to the dispute pays the entire certified entity fee when it makes its offer of payment. Once the certified IDR entity makes its decision, it refunds the certified entity fee to the prevailing party within 30 business days of the date of its decision. If the parties settle their case, each party pays half of the certified entity fee unless they agree otherwise.
The IDR Process
The new guidance clarifies several points about the IDR process, including the following:
- The federal IDR process does not replace the external claims review process, which concerns adverse benefit determinations for enrolled individuals.
- Parties to payment disputes can submit supporting written documentation in addition to that required by the IDR process, but no hearings are held.
- Each state has separate IDR rules.
HBL has experience in all areas of benefits and employment law, offering a comprehensive solution to all your business benefits and HR/employment needs. We help ensure you are in compliance with the complex requirements of ERISA and the IRS code, as well as those laws that impact you and your employees. Together, we reduce your exposure to potential legal or financial penalties. Learn more by calling 470-571-1007.
Hall Benefits Law, LLC
Latest posts by Hall Benefits Law, LLC (see all)
- Penalties for Failing to Timely File 2023 Forms 1094/1095 - April 18, 2024
