As Congress enacted the No Surprises Act in 2020 to address the issue of “surprise medical bills” for patients and provider payment issues, the Biden administration has proposed a recent rule specifically addressing the Independent Dispute Resolution (IDR) process.

 

The federal IDR process begins when either a provider or a payer disputes the payment amount for a claim or “batch” of claims. The IDR process permits certain items/treatments to be “batched” together for the IDR process with a goal of making the process more efficient. This most recent proposed rule would do a number of things.

 

Notably, it would raise the current fee for either a provider or a payer to initiate a payment dispute. Last year, the administration proposed a fee increase from $50 in the Act, to $350. A federal court struck down the fee increase and the administration has since proposed a new increase in this rule from $50 to $150.

 

The rule would also place additional restrictions around “batching.” Specifically, the rule would allow batching of following items/services:

“(1) items and services furnished to a single patient on one or more consecutive dates of service and billed on the same claim form (a single patient encounter);

(2) items and services billed under the same service code or a comparable code under a different procedural code system; and

(3) anesthesiology, radiology, pathology, and laboratory items and services billed under service codes belonging to the same Category I CPT code section, as specified in guidance by the Departments, in order to address the unique circumstances of these medical specialties and provider types.”

 

There would also be a limit of 25 items/services in a single dispute to facilitate more timely resolutions.

 

The rule language also addresses timeliness of IDR eligibility determinations. Part of the large backlog of IDR cases at the federal level is due to a delay in eligibility determinations of parties initiating a dispute. Currently there is required timeline in the Act to determine whether a party is eligible for the IDR process. The rule language would require the eligibility determination to be made within five (5) days of when a certified IDR entity selection. It would also require parties to submit requested information to the IDR entity within five (5) days of the entity’s request for that information. 

 

 

 

On November 8, 2023, the State Medical Board of Ohio met. There were no new items of regulatory or legal significance for Ohio physicians. However, the Board did continue to promote awareness of its newly implemented Confidential Monitoring Program, specifically encouraging any interested to attend one of the webinars offered by OhioPHP (the third-party administrator of this physician wellness program). As a reminder, this summer the Board eliminated the previous One Bite Program addressing physician substance use impairment in favor of a vastly more appropriate program structure. The new program is completely confidential, incorporates physician mental and physical health impairment, not simply substance use. It creates specifically tailored treatment programs for each of its participants, rather than a one-size fits all approach.