The buzz around this year’s Self-Insurance Institute of America (SIIA) National Conference & Expo was the status and outlook of the No Surprises Act (NSA) and the comprehensive legislation challenges to addressing surprise medical billing at the federal level.
Most sections of the legislation went into effect Jan. 1, 2022, and the Departments of Health and Human Services, Treasury, and Labor are tasked with issuing regulations and guidance to implement a number of the provisions.
As the world’s largest self-insurance event, SIIA drew a diverse audience from within the self-insurance marketplace. These perspectives provided insights and key takeaways.
The Independent Dispute Resolution (IDR) process is ineffective
Significantly more IDR initiations have occurred than anticipated by the government.
90,000 appeals were initiated in less than six months. The Centers for Medicare and Medicaid Services (CMS) initial estimate was 22,000 for the entire year. Only 3,500 determinations have been made.[i]
There are simply not enough IDR Entities (arbitrators) given the currently number of thirteen, and one is not accepting new disputes.
The process is occurring piecemeal
The IDR is initiated in the federal portal, but then every other step is managed by the IDR Entity. Each arbitrator manages the process differently, some by e-mail, some by their own portal. Progress is difficult to track and monitor. Arbitrators are also not following the deadlines, but rather pausing the acceptance of offers upon receipt of new disputes
The fees to the IDR Entities have been increased to $700 for single determinations and $938 for batched determinations. However, with the requirement of a written decision for each IDR arbitration, even that increase is not likely to be enough incentive to eliminate the ever-increasing backlog of unresolved cases.
No reporting yet of any decisions
CMS has not provided results regarding the 3,500 cases that have been resolved. We do not know which decisions accepted provider or payor offers in arbitration.
Employer sponsors should take strategic action to ensure their plans incorporate the most effective strategies for NSA compliance.
[i] Centers for Medicaid & Medicare Servs., Calendar Year 2023 Fee Guidance for the Federal [IDR] Process under the No Surprises Act, 10/31/22. “… Between the launch of the Federal IDR portal on April 15, 2022, and September 30, 2022, parties initiated more than 90,000 disputes through the Federal IDR portal, which is substantially more than the Departments’ initial estimates. During that time, non-initiating parties challenged over 41,000 disputes’ eligibility for the Federal IDR process, which constitutes nearly half of all disputes initiated. These contested eligibility disputes involved complex eligibility determinations that have required certified IDR entities to expend considerable time and resources to review. As a result of eligibility challenges, as of September 30, 2022, certified IDR entities have found over 22,000 disputes ineligible for the Federal IDR process. While the process for eligibility determination informs the overall rate that certified IDR entities are permitted to charge, certified IDR entities may not collect fees for those cases that they ultimately determine are ineligible for the Federal IDR process. Further, only about 3,500 payment determinations were made by certified IDR entities. …” Accessed 11/22/22 at: https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/CY2023-Fee-Guidance-Federal-Independent-Dispute-Resolution-Process-NSA.pdf