Federal IDR Process Guidance Issued for Disputing Parties and Certified Entities

The DOL, HHS, and IRS recently issued revised Federal Independent Dispute Resolution (IDR) Process Guidance for certified IDR entities and for disputing parties. The Federal IDR Process Guidance outlines the IDR process used by plans, insurers, providers, and certified IDR entities in resolving claims for payment for out-of-network services that are subject to the federal No Surprises Act surprise billing rules.

The Federal IDR Process Guidance was updated mainly to reflect a recent court ruling in Texas Medical Association v. HHS that vacated portions of the final regulations related to the information a certified IDR entity must consider in making a payment determination and the information required to be included in a certified IDR entity’s written decision. (See the February 16, 2023, article in Compliance Corner). The court determined that the final regulations issued in August 2022 swayed the IDR negotiation process in favor of the qualifying payment amount (QPA) by requiring certified IDR entities to consider the QPA before considering other information and limiting the situations where other information submitted by a party may be considered. In response to the court decision, the revised Federal IDR Process Guidance instructs certified IDR entities to consider both QPAs and other information to determine the payment amount.

The revised Federal IDR Process Guidance is effective for payment determinations made on or after February 6, 2023, for items and services furnished on or after October 25, 2022, for plan years beginning on or after January 1, 2022. Prior guidance issued on October 31, 2022, applies to payment determinations made before February 6, 2023, for items and services furnished by an out-of-network provider on or after October 25, 2022.

The revised Federal IDR Process Guidance is expected to accelerate the IDR payment determinations process again. Previously, payment determinations involving items or services furnished on or after October 25, 2022, have been on hold pending further guidance from the agencies. Particularly, employers with self-insured plans should review the revised Federal IDR Process Guidance to be familiar with the latest IDR process.

Federal Independent Dispute Resolution (IDR) Process Guidance for Disputing Parties »
Federal Independent Dispute Resolution (IDR) Process Guidance for Certified IDR Entities »