CMS revises and resumes surprise billing arbitration after physician group's legal win

The Centers for Medicare & Medicaid Services (CMS) has restarted its surprise billing arbitration process after revising it in response to a legal victory by a physician group.

CMS’ new guidance to arbiters, or Independent Dispute Resolution (IDR) entities, instructs them to consider all evidence without weighting the Qualifying Payment Amount (QPA) more heavily than any other factor. CMS also announced that as of March 17, disputing parties will begin receiving a majority of their payment determination notices from the IDR portal, specifically from auto-reply-federalidrquestions@cms.hhs.gov. Disputing parties are advised to make note of this email address.

The Texas Medical Association filed a lawsuit last year challenging the No Surprises Act rule that describes the arbitration process. Physician groups and hospitals argued that weighting the QPA, which is generally the median contracted rate for the same or similar item or service in 2019, gave payers an advantage because they set the rates. Ruling in favor of the Texas Medical Association, a federal court concluded the challenged portions of the rule were unlawful and must be set aside. CMS suspended the arbitration process last month, then issued revised guidance for the IDR process that takes into account the court order.

IDR entities are to use the updated guidance when issuing payment determinations for items and services furnished on or after Oct. 25, 2022. Updated guidance for disputing parties is also available for that timeframe. Disputes involving items or services furnished before October 25, 2022, are not affected by the court decision.

— Brennan Cantrell, AAFP Commercial Health Insurance Strategist

Posted on March 30, 2023