On January 1, 2022, the No Surprises Act took effect to protect patients from surprise medical expenses, but it has created tension between payers and providers. For example, on February 23, 2022, the U.S. District Court for the Eastern District of Texas struck down the part of the interagency interim final rule implementing the “independent dispute resolution” (IDR) procedures.
When payers and out-of-network providers cannot agree on reimbursement, either party can choose to initiate an IDR. While the majority of the rule remains in effect, the changes from this case will impact health plans and the insurers that sponsor them.
These were the key themes of a recent Future Healthcare Today podcast interview with Matthew Albright, Chief Legislative Affairs Officer at Zelis, and Cate Brantley, Legislative Analyst at Zelis, who provided a deep-dive perspective on the IDR process and its impact on health payers.
“We have seen a history of the transparency requirements being successful in court, and it looked like this rule would be set in stone,” said Albright. “The court’s decision hands healthcare providers a win when it comes to that arbitration process, because under the court’s ruling, the arbiter now has to consider five different factors instead of just one when deciding what the proper reimbursement should be. The ruling will make the arbitration process more complex and more subjective. In essence, providers will have a better chance of getting reimbursed higher than the in-network rate.”
Listen to the full podcast below: