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Earlier today, the Department of Labor, the Treasury, and the Department Health and Human Services Centers for Medicare and Medicaid Services (the "Departments") issued a new directive to Certified Independent Dispute Resolution (IDR) Entities regarding issuing payment determinations for certain pending out-of-network (OON) disputes.
Effective February 27, 2023, Certified IDR Entities will resume issuing payment determinations for disputes related to services and items furnished prior to October 25, 2022.
The announcement comes just two weeks after the Departments directed Certified IDR Entities to hold all pending payment determinations, in light of the U.S. District Court for the Eastern District of Texas' opinion on February 6, 2023, in the matter of Texas Medical Association, et al. v. United States Department of Health and Human Services, Case No. 6:22-cv-372 (TMA II), which vacated specific rules governing the Federal IDR decision-making process for disputes related to OON providers, facilities and air ambulance providers. In that February 10, 2023 directive, the Departments also instructed Certified IDR Entities to recall all payment determinations issued on or after February 6, 2023.
Certified IDR Entities will soon resume processing disputes for dates of service prior to October 25, 2022 – dates that correlate to time periods not affected by TMA II and the regulatory provisions that were vacated. Certified IDR Entities are directed to refer to the Departments' previously issued guidance for resolving disputes. The guidance is available here: Federal Independent Dispute Resolution Process Guidance for Certified IDR Entities (cms.gov).
IDR payment determinations for services and items furnished on or after October 25, 2022 are still on hold, pending additional guidance from the Departments.
In today's announcement, the Departments also reminded parties that the Federal IDR eligibility, timelines for open negotiation and initiation of IDR, and other aspects of the IDR process have not changed.
If you have questions about eligibility for the Federal IDR process, or about other No Surprises Act requirements, the health care team at Sheppard Mullin will be happy to assist you.
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