The No Surprise Billing Act went into effect on January 1, 2022, and affects physicians that see patients who are uninsured or who self-pay for medical services.
Per the guidelines of the act, patients can no longer be balance billed for services. Therefore a new process was put in place for physicians to notify patients up front what they can expect to pay out of pocket if services are not covered under an insurance plan. This rule is called the Good Faith Estimate (GFE) and a sample GFE form can be seen here: https://www.cms.gov/files/document/good-faith-estimate-example.pdf. The estimate is provided to the patient prior to their visit and is based upon when the patient scheduled their visit. For further information on the GFE, please visit https://www.cms.gov/nosurprises/policies-and-resources/provider-require….
With the implementation of the No Surprise Billing Act and protections against out-of-network balance billing also comes a new process to dispute claims paid with insurers. Physicians and facilities can no longer dispute a denial, or an amount paid to them directly with the patient, and must follow a new process called Independent Dispute Resolution (IDR). This process is initiated through CMS, and a portal guides the user through a questionnaire that determines if the claim is eligible for dispute.
The CMS Independent Dispute Resolution Process:
- Brings in a third-party, known as a certified independent dispute resolution entity, to decide the payment amount. The parties have an opportunity to select the independent dispute resolution entity from a list of certified organizations, and everyone involved must attest to having no conflicts of interest
- Requires the provider or facility and the health plan to submit payment offers to the dispute resolution entity and additional information supporting their payment offers.
- Requires the dispute resolution entity to select from the disputing parties’ payment offers. Both the provider or facility and the health plan must abide by the entity’s decision and payment must be made within 30 calendar days.
At the onset of the IDR process implementation, the negotiated amount to be paid to the provider was based on the Qualifying Payment Amount (QPA), which was a calculated average payment amount determined by specialty and region for the service rendered. Due to a recent ruling by a federal judge, the negotiated rate has since been revised and is now based not wholly on the QPA but more heavily on the physician’s level of training or experience, clinical quality and outcomes, market share, patient acuity, service complexity, teaching status, case mix, and scope of services of the facility, and good faith efforts by either party to enter into in-network agreements and contracted rates.
If your practice needs more information about the IDR process or would like to open a dispute, please visit the following CMS link to learn more about the process.
If you have additional questions about No Surprise Billing Act and the IDR process, please contact My Practice at 213-473-8630 or via email at MyPractice@CAPphysicians.com for immediate assistance.
My Practice was created as part of CAP’s commitment to providing you with valuable products, services, and resources to support a successful medical practice, so you can spend more time focusing on superior patient care.
Andie Tena is CAP’s Director of Practice Management Services. Questions or comments related to this column should be directed to ATena@CAPphysicians.com.