The methodology to be used in the determination of the out-of-network payment is the area of greatest concern to healthcare providers. Providers must include information on the size of the practice and the practice specialty, but they may not submit information that relates to usual and customary charges, billed amounts, and public payer rates (such as Medicare). Once the certified IDR entity is chosen, each party must submit within 10 days an offer for a payment amount of the item or service in dispute, along with other information related to the offer. If an objection is filed, then the objecting party must propose an alternative if no agreement is reached within another three days, then the federal agencies will randomly select an entity. The chosen entity will be accepted unless the other party objects within three days. The written notice must include the initiating party's preferred certified IDR entity chosen from the list that will be available from the federal portal. 2 A federal portal for initiating the IDR will become available once the law takes effect, although it is unknown if using the portal will satisfy the notice to both the payer and the federal agencies. The federal IDR process must be initiated during the four-day period beginning on the 31st day following the initiation of the open negotiation period by sending a written notice (on paper or electronically) to the other party and to the federal departments administering the process. If they cannot agree, then the 30-day period must run out before the next step can begin. The negotiation period can last for up to 30 days, beginning with the date of the written notice it ends if the parties agree on an out-of-network rate. An offer of the payment the practice would accept.The service code (typically the current procedural terminology or CPT code).The date the item or service was furnished.Written notice, which could be on paper or electronic, must be given to the payer to begin the negotiation, and it must include the following: The 30-day period begins on the date the practice receives the initial payment or notice of denial, so an internal process that gives prompt attention to the accounts of out-of-network patients is essential. Once the practice decides that it is not willing to accept the level of payment (or denial of payment) made by a payor for a particular out-of-network service, it has 30 days 1 to open a negotiation with the payor. The process includes several distinct steps that must be followed exactly in order to have an enforceable result: However, what was unknown until the September regulations were issued was how the practice would resolve a payment dispute with the payer using the Independent Dispute Resolution (IDR) system that was loosely defined in the law. Determine which payors are out of network.Determine if the law applies to your practice.The steps we outlined are important for compliance with the new law, including the following: For example, the American College of Radiology (ACR) wrote in its detailed summary of the rule that it "is disappointed that the regulations violate the intent of the No Surprises Act (NSA) by making the Qualified Payment Amount (QPA) the primary determinant of physician payment rates in the independent dispute resolution process."Įarlier this year, we provided a summary of the new law and a suggested an action plan for practices to use. ![]() At the end of September, long-awaited regulations that will govern the details of its implementation were issued and were met with displeasure by healthcare providers.
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