As readers probably know, the No Surprises Act (NSA) Independent Dispute Resolution (IDR) process was set up by the Centers for Medicare & Medicaid Services (CMS) to mediate payment disputes between payers and providers on out-of-network “surprise” claims. CMS expected about 17,000 claims would be submitted through the federal IDR portal every year.

A recent analysis, however, found that 14 times that amount of claims — nearly 700,000 — were submitted through the IDR portal over just nine months last year. [1] It’s no surprise then that the IDR process is completely overwhelmed, and the portal itself is too rudimentary to effectively manage the process. Numerous articles report that the process is backed up with tens of thousands of claims that have yet to be settled.[2]

In response, CMS has proposed changes to the IDR portal and process in a recent rule, including significant technical upgrades and procedural requirements, in an effort to resolve ongoing concerns from both payers and providers and to ensure timely payment determinations are made.

While leaving the basic structure of the IDR process intact, the proposed rule envisions a greatly enhanced IDR portal that would manage all negotiation and IDR-related communications between parties. The rule also greatly increases the amount of notices, content within notices, and overall communications that would need to take place between the parties.

Ultimately, the proposed changes and upgrades should help streamline the process and make the experience more seamless and “digital.” However, that’s not to say they won’t necessitate some heavy lifts from both payers and providers.

Let’s start by tackling one of the most expansive proposed additions to the process: The IDR registry.

This proposed component requires health plans or issuers to have assigned registry numbers that identify them within the IDR portal and throughout the process. Many of the delays in the IDR process to date occur because the parties don’t have accurate and timely information about the claim, and communication between the parties is manual and cumbersome. The goal of the registry is to clearly indicate the payer and the payer’s contact information to improve info-sharing between parties.

The proposed rule requires payers to submit general information in order to acquire an IDR registry number. Completion of the registry number application will be managed within the federal portal. In fact, pretty much everything will be managed in the portal now – from start to finish.

According to the proposed rule, payers must register for a registry number by the date that is the later of:

  • 30 business days after the effective date of the final rule; OR
  • The date that is 30 business days after the registry becomes available.

CMS indicated that the effective date of the final rule may be as early as August 2024, though, given the time required to draft and publish a final rule, it is more likely to take effect later than that.

Payers must also:

  • Report any changes to their registry info within 30 calendar days of a change; and
  • Confirm the accuracy of the information in Q4 of every year.

Payers will be required to provide the following information when registering:

  • Legal name of plan or plan sponsor
  • Self-funded or fully insured designation
  • State the plan is subject to for surprise billing laws if self-funded or the plan has opted into a state law
  • Health Insurance Oversight System Identifier (HIOS), or EIN and the plan’s Plan Number (PN)
  • Additional information to be specified by CMS in guidance

CMS clarified that third parties with authority to act on behalf of a plan may register such plan in the registry. Because of the administrative lift required by the proposed rule, payers may want to use third parties to gather the required info, register the payer, maintain the information in the registry, and manage any reporting for the registry that is required.

The next big, proposed change to the IDR process and portal deals with the open negotiations period. Stay tuned for more on that soon.

[1] “No Surprises Act Continues to Prevent More than 1 Million Surprise Bills Per Month, While Provider Networks Grow” by BlueCross BlueShield Association and American Health Insurance Plans, January 2024

[2] “No Surprises Act Purportedly Pushing Providers in Radiology and Other Specialties ‘To the Brink’,” by Radiology Business, November 2023