The DOL, HHS, and IRS have jointly issued a report with usage data on the surprise billing independent dispute resolution (IDR) process created when the Consolidated Appropriations Act of 2021 (CAA, 2021) expanded protections for patients to protect people from surprise bills for certain out-of-network emergency and non-emergency services. The CAA, 2021 and the regulations addressing the procedural aspects of plan payments to non-participating providers, including the role of IDR certified entities, require agencies to publish quarterly reports highlighting IDR activity (see our Point of View control Article). Data for reporting comes from certified IDR entities and federal HHS IDR portalwhich opened on April 15, 2022 (see our Checkpoint Article).
The agencies released a report representing two-quarters of the data from April 15 to September 30, 2022. Notably, 90,078 disputes were initiated by disputing parties through the IDR portal, but only 23,107 were closed during the period, a often due to processing delays when parties contested their disputes’ eligibility for the federal IDR process. Of the closed disputes, more than two-thirds of those involving non-emergency and emergency services were ineligible for the federal IDR process, and nearly half of the closed air ambulance disputes were ineligible. Explaining that eligibility depends on several factors, including determining state vs. federal jurisdiction, correct batch and package processing, adherence to applicable time periods, and completion of open negotiations, the report notes that 22 states have state laws that protect consumers from surprise billing and provide a method to determine the payment amount in certain circumstances. A table listing disputes filed by state reveals that 60% of all disputes were filed in Texas, Florida, Georgia, Tennessee, and North Carolina, despite the fact that Texas, Florida, and Georgia have a state process that would apply to payment disputes for certain items and services. Another table tracking disputes over services provided under Current Procedural Terminology (CPT) codes indicates that the most common CPT codes involved in disputes were emergency department service codes (66% of disputes). , radiology codes (9% of disputes) and anesthesia codes (7% of disputes).
EBIA Comment: The agencies claim that this initial partial reporting was delayed because parties filed significantly more disputes than the agencies initially estimated, and the IDR portal’s reporting functionality required substantial manual processing. The IDR administrative fee was increased for 2023 to reflect the increasing volume of disputes and the additional expenses associated with the enhanced role of agencies in conducting pre-eligibility reviews to address a growing backlog of disputes (see our Checkpoint Article). For more information, see EBIA’s health care reform manual at Sections XII.B.3 (“Surprise Medical Billing: Emergency and Non-Emergency Services”) and XII.B.4 (“Billing of Surprise Air Ambulance”) and the EBIA Group Health Plan Mandates Manual in Section XIII.B (“Patient Protection”). Also see EBIA’s Self-Insured Health Plans manual in Section XIII.C (“Federally Required Benefits”).
Contributing editors: EBIA staff.
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