America's Benefit Specialist January-February 2023

BENEFIT REPORTING

pricing plan, it becomes more complicated. In a fully insured plan, the carrier will deal with the QPA and the IDR. In a self-funded plan, the plan sponsor, TPA or ASO vendor will be directly involved. Under the NSA, if a self-funded health plan and an out-of network provider cannot agree on a payment rate, they must go through the new independent dispute resolution (IDR) process. The Interim Final Rule states the contracted rates between providers and the network provider for the health plan would be treated as the self-insured plan’s contracted rates for purposes of calculating the QPA. A median contract rate should be determined by taking into account every group health plan offered by the self-in sured plan sponsor. The Interim Final Rule (IFR) allows for ad ministrative simplicity for self-funded plans to permit the TPA that processes their claims to determine the QPA for the plan sponsor by calculating the median contract rate based on all of the plans that it processes and administers claims for. The IFR states that the contracted rates between providers and the network provider for the health plan would be treated as the self-insured plan’s contracted rates for purposes of calculating the QPA. INDEPENDENT DISPUTE RESOLUTION PROCESS If a payer such as a carrier or health plan cannot resolve a payment settlement with a provider, then the payer and provider must resolve the payment dispute using methods of negotiation and arbitration. The No Surprises Act requires payers to send an initial payment or denial of payment of a claim no longer than 30 days after a claim is submitted. After the 30-day period, either party may begin negotiations on a claim. If the parties involved cannot agree on payment terms during the 30-day period, then they will move to an IDR process. This process may be initiated within four days of the 30-day period (for a 34-day window). Each entity will offer a final payment amount, then the arbiter will use a variety of factors to determine the final amount, including geographic areas, service codes, etc. The intent is to make it fair to both parties. Under the IDR pro cess, they are not allowed to use lower payment rates such as Medicare or Medicaid. The IDR does not impact the consumer or plan participant. The dispute is between the provider and the health plan. The provider has no recourse against the consumer and, there fore, it is not an adverse benefit determination. It’s important to note that the IDR uses baseball-style arbitration, meaning that the arbiter must select one offer or the other. There is no splitting the difference. Therefore, it’s important that the parties submitting the dispute into the federal portal must take time and fully understand the process in order to win in an arbitration case within the IDR. On August 19, 2022, the federal departments released the Final Rule implementing the IDR process under the NSA. In

this release, they noted that, effective 60 days after publica tion in the Federal Register, the following modifications were made in the NSA: a) eliminates the rebuttable presumption standard b) increases claims downcoding transparency c) strengthens arbitration explanation In the final rules, they released an IDRE (certified indepen dent dispute resolution entity, or federal arbiter) Fact Sheet, provided a status update on arbitration claims, and released FAQs related to Surprise Billing and Transparency in Cover age Rule. The Federal IDR Portal did not open on January 1, 2022, as expected. It was delayed until April 15, 2022. The departments released an update on the IDR portal with the final rules. It’s important to note that the cases are seriously backlogged due to the delay in opening the portal. In addition, only 12 CI DREs (arbiters) were approved to date, and two have stopped taking new cases, leaving only 10 companies providing arbi tration services in the portal. Data on the first period’s activity (April 15 to August 11, 2022) includes the following: a) 46,000 total number of disputes initiated, which was “sub stantially more than the departments initially estimated would be submitted for a full year” b) 1,200 cases in which CIDREs have made a payment deter mination c) 21,000 non-initiating party challenged eligibility – nearly half of the disputes d) 7,000 disputes were found ineligible by CIDREs I want to point out that cases have resulted in approxi mately 60/40 in favor of providers, where early indications were that health plans had the advantage. Is this perhaps be cause providers are doing a better job of providing additional information? In my opinion, it would appear so. Providers have been studying the rules and practicing submitting “additional information” that would increase their payment amounts. Health plans appear to have not done such home work, and those submitting the dispute information, such THE IDR DOES NOT IMPACT THE CONSUMER OR PLAN PARTICIPANT. THE DISPUTE IS BETWEEN THE PROVIDER AND THE HEALTH PLAN.

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