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No Surprises Act Replace: Licensed IDR Entities to Resume Fee Determinations for Providers Furnished Earlier than October 25, 2022


Earlier right now, the Division of Labor, the Treasury, and the Division Well being and Human Providers Facilities for Medicare and Medicaid Providers (the “Departments”) issued a new directive to Licensed Impartial Dispute Decision (IDR) Entities relating to issuing fee determinations for sure pending out-of-network (OON) disputes.

Efficient February 27, 2023, Licensed IDR Entities will resume issuing fee determinations for disputes associated to providers and objects furnished previous to October 25, 2022.

The announcement comes simply two weeks after the Departments directed Licensed IDR Entities to carry all pending fee determinations, in gentle of the U.S. District Courtroom for the Jap District of Texas’ opinion on February 6, 2023, within the matter of Texas Medical Affiliation, et al. v. United States Division of Well being and Human Providers, Case No. 6:22-cv-372 (TMA II), which vacated particular guidelines governing the Federal IDR decision-making course of for disputes associated to OON suppliers, amenities and air ambulance suppliers. In that February 10, 2023 directive, the Departments additionally instructed Licensed IDR Entities to recall all fee determinations issued on or after February 6, 2023.

Licensed IDR Entities will quickly resume processing disputes for dates of service previous to October 25, 2022 – dates that correlate to time durations not affected by TMA II and the regulatory provisions that have been vacated. Licensed IDR Entities are directed to confer with the Departments’ beforehand issued steering for resolving disputes. The steering is offered right here: Federal Impartial Dispute Decision Course of Steering for Licensed IDR Entities (cms.gov).

IDR fee determinations for providers and objects furnished on or after October 25, 2022 are nonetheless on maintain, pending further steering from the Departments.

In right now’s announcement, the Departments additionally reminded events that the Federal IDR eligibility, timelines for open negotiation and initiation of IDR, and different features of the IDR course of haven’t modified. 

When you’ve got questions on eligibility for the Federal IDR course of, or about different No Surprises Act necessities, the well being care workforce at Sheppard Mullin will likely be glad to help you.




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