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Officials in the administration of President Donald Trump want health insurers and health plan administrators to help make the No Surprises Act independent dispute resolution system work better by changing how they communicate with out-of-network providers about claims.
Administration officials have put the new payer communication requirements in a new No Surprises Act IDR system final rule.
The new final rules require health insurers and self-insured employer health plans to register with a new IDR Gateway claim management platform.
A payer will have to give the IDR Gateway system contact information and some other basic coverage, such as a description of the coverage type and a list of the states that have jurisdiction over the coverage.
Payers will also have to use standard "claim adjustment reason codes" and "remittance advice remark codes" in any communications about claims with out-of-network providers, to help the providers determine whether disputes about claims are eligible for the No Surprises Act dispute resolution process.
When a provider sends a claim to an "IDR entity," or organization that handles No Surprises Act claim disputes, the payer will have to answer any IDR entity questions about whether the dispute is eligible for the dispute resolution process within five business days. If a payer fails to answer the IDR entity's eligibility questions within five days, the IDR entity can proceed without the requested information or simply close the case.
Providers will also be subject to the five-day response time deadline.
The U.S. Department of Health and Human Services' Centers for Medicare & Medicaid Services developed the new final regulations together with the U.S. Treasury Department's Internal Revenue Service and the U.S. Department of Labor's Employee Benefits Security Administration.
At press time, the agencies had posted a preliminary version of the final rule on the CMS website and were preparing to publish the final rule in the Federal Register — an official rulemaking publication — within a few days.
What it means: Employers, employer plan administrators and group health insurance issuers will soon have to register with the IDR Gateway and meet tough deadlines for answering questions from IDR entities.
Eventually, the IDR Gateway system could create tracking dashboards that could help employers and their benefits advisors analyze claims and fend off claims that are not eligible for the No Surprises Act process.
The No Surprises Act: The No Surprises Act dispute resolution system applies to some patients with commercial health coverage who get care from out-of-network doctors in in-network hospitals, and to insured patients who get emergency care at out-of-network hospitals.
The system also affects insured patients who use air ambulance services.
The "IDR entities" provide what look like No Surprises Act claim arbitration services, but whether the claims are arbitration cases and whether the IDR entities can be described as arbitrators is subject to litigation in the federal courts.
Regulation details: Many of the requirements in the final rule are set to apply within 90 days after the official Federal Register publication date.
CMS, EBSA and the IRS still have to set up the IDR Gateway dispute management platform.
Once the IDR Gateway is working, existing employer plans and health insurers will have 90 days to register with the system.
Any insurer or self-insured employer plan that starts up after the IDR Gateway system comes to life will have 90 days after it begins offering coverage to register.
Officials are expecting the IDR Gateway registration process to apply to 1,585 health insurers and employer plan administrators.
Some commenters asked regulators to require insurers and self-insured plans to put basic IDR information on plan participants' identification cards.
Regulators have not added ID card requirements in the new final rule. But, in the "preamble," or official introduction, to the regulations, officials said their agencies "will consider these comments as they explore future rulemaking related to ID cards."
The backdrop: Insurers, employers and payer groups have complained that the IDR entities rule in favor of the providers involved in No Surprises Act claim disputes most of the time and award payment rates that are far above the payment rates that in-network providers in a community would typically receive for providing similar services.
Regulators do not appear to say much, if anything, about the payers' concerns about fairness in the 607-page final rule packet.
The emphasis on payer communication requirements in the final rule may be a sign that officials agree with the providers that many of the problems are the result of incomplete or inaccurate payer communications.
Reactions: America's Health Insurance Plans, a group for health insurers, gave the new final rule a mixed review.
"While the focus on addressing flawed incentives in the IDR process is a significant first step, more action is needed to protect Americans from unconscionable price gouging by some PE-backed providers and IDR middlemen," AHIP representative Chris Bond said.
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