On December 21, 2023, the IRS, DOL, and HHS (collectively, the agencies) issued a final rule related to fees established by the No Surprises Act for the federal independent dispute resolution (IDR) process under the Consolidated Appropriations Act, 2021 (CAA). The IDR process comes into play when health plans and issuers and providers, facilities and providers of air ambulance services cannot agree on an appropriate payment for out-of-network items and services. Two types of fees apply to the process: an administrative fee paid to the applicable federal agency and a fee paid to the certified IDR entity.
The final rule, finalizing the proposed rule from September 2023, amends the existing regulations following an August 3, 2023, Texas court case (Texas Medical Association v. HHS; see August 17, 2023, Compliance Corner article) that set aside an increase in IDR fees that were established without official regulatory action. The final rule provides that, going forward, the administrative and IDR entity fees will be established by the agencies in notice and comment rulemaking (no more frequently than once per calendar year) rather than by guidance published annually. The CAA requires that the administrative fees paid each year should be estimated to be equal to the amount of expenditures that are estimated to be made by the agencies each year in carrying out the IDR process.
The final rule also sets the fees for disputes initiated on or after the effective date of the final rule, which is January 20, 2024. The administrative fee will be $115 per party. The certified IDR entity fee will range from $200 to $840 for single determinations and $268 to $1,173 for batched determinations. Certified IDR entities may establish an additional fee, ranging from $75 to $250 for each increment of 25 dispute line items included in a batched dispute, beginning with the 26th line item. The agencies also issued a fact sheet that summarizes the Final Rule.
Most plan sponsors rely upon their carrier or TPA to resolve out-of-network payment disputes subject to the No Surprises Act but should have a general awareness of the IDR process and related guidance.
Final Rule
Fact Sheet
PPI Benefit Solutions does not provide legal or tax advice. Compliance, regulatory and related content is for general informational purposes and is not guaranteed to be accurate or complete. You should consult an attorney or tax professional regarding the application or potential implications of laws, regulations or policies to your specific circumstances.
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