The Independent Dispute Resolution (IDR) ruling within the No Surprises Act oversees the mediation process between payers and out-of-network providers when they cannot agree on reimbursement. The Centers for Medicare & Medicaid Services (CMS) is currently updating its guidance on the IDR process to consider more than just the qualifying payment amount (QPA) when determining reimbursement amounts.
To further this discussion, industry experts from Zelis, Matthew Albright, Chief Legislative Affairs Officer, and Adam Brenman, Legislative Analyst, spoke with Future Healthcare Today about CMS’s recent changes to the IDR process under the No Surprises Act. CMS has “established the IDR process to help with the disputes when a plan is offering one reimbursement rate, but the providers want a different rate,” commented Brenman. “This is already operationalized and in place as of January this year.”
CMS continually works to improve processes and policies and build tools that aid providers and health plans. One improvement is a notice of offer form. Brenman stated that “this would be used by parties in the IDR process and require them to submit a notice of offer to the IDR entity, which indicates how much each party believes that their service is worth for reimbursement purposes.” Until October, this system was not standardized, leading to disputes when submitting notices. Therefore, CMS created this new web form for notice of offers.
Another new solution is process initiation screening questions, commonly referred to as “screeners.” This is a “way to enhance customer experience, better screen IDR disagreements, and supply providers with more information prior to submitting a dispute,” explained Brenman. CMS released these system improvements to the IDR portal, including “three eligibility screeners for providers to run through before their submissions that act as a checklist.” The goal of these recent changes is to streamline the process for the IDR portal.
While some contention may remain, CMS is taking important steps towards creating solutions to mitigate the challenges to the IDR process. These improvements are only the beginning of many solutions to come for the policies and the regulatory process. With the mission to help smooth the process for providers, payers, and other participants in the IDR process, CMS is determined to provide improved guidance.