EDPMA in our partnership efforts with the American College of Emergency Physicians (ACEP) have worked to highlight the issues our members are experiencing with health plan compliance with their obligations under the No Surprises Act.  After sending multiple letters with examples of health plan non-compliance and meeting with staff from the Center for Consumer Information and Insurance Oversight (CCIIO), EDPMA is pleased to announce that CCIIO has released a new guidance document, Federal Independent Dispute Resolution Process Checklist of requirements for group health plans and group and individual health insurance issuers.

The full document can be accessed here.

EDPMA’s members consistently report that health plans are not providing federally required information to bill patients’ out-of-network services and to proceed with the federal Open Negotiations and Independent Dispute Resolution (IDR) processes that are part of the No Surprises Act.  To advocate on your behalf, we wrote a letter to federal agencies last month that provided: 1) specific examples of health plan non-compliance; and 2)  policy recommendations that would help address these non-compliance issues. EDPMA thanks our members who shared their redacted data to support this advocacy effort.

Last week, EDPMA and ACEP met with the Center for Consumer Information and Insurance Oversight (CCIIO) at the Centers for Medicare & Medicaid Services (CMS) staff to follow-up on our letter.  During the meeting, we described to CCIIO what specific health plan non-compliance issues we are experiencing, provided specific recommendations, and also requested additional guidance on how we should proceed with the Open Negotiations and IDR processes when there is limited or missing information from health plans (information that was required by the first interim final rule implementing the No Surprises Act).  We also emphasized the critical need for strong enforcement to ensure health plans provide information as required by law.

CCIIO made two important points about complaints:

1. If a complaint remains unresolved and the timelines around the Open Negotiation and IDR processes become difficult to adhere to, disputing parties can file for an extension.
   • As outlined in the IDR guidance (page 29), you file for an extension due to extenuating circumstances by emailing a Request for Extension due to Extenuating Circumstances to FederalIDRQuestions@cms.hhs.gov.
   • We explained to CCIIO that this solution is not optimal for providers since it delays when they would receive an appropriate payment from health plans, and it allows health plans to keep funds that they owe to providers.
2. You are allowed to “batch” complaints against one health plan.  In other words, instead of submitting a complaint for each individual claim, you can submit all the complaints against one health plan at once.  This may help save time and speed up the time in which your complaints are processed and adjudicated by CMS.

CCIIO staff stated that they heard many of these issues before and have received many complaints from providers that health plans are not providing all the required information.  CCIIO also claimed they resolved about 25% of all complaints, and there is a significant backlog of unresolved complaints.  Further, they stated that when a complaint is resolved, they request documentation from the health plan and continue to work with them to systematically resolve similar complaints moving forward. While CCIIO confirmed they are hosting internal conversations about how to enforce non-compliance, they did not offer specifics on enforcement processes or outcomes.

We believe the meeting was productive and we are reassured that CCIIO is acutely aware of these issues and is taking them seriously. Because CCIIO did not commit to adopting our policy recommendations, we will continue to follow-up with CCIIO on these requests.

As always, EDPMA has your back by advocating on your behalf and providing the resources you need to manage a successful business.

As a reminder, you can submit billing complaints by clicking here or by contacting the No Surprises Help Desk at 1-800-985-3059.

On March 22, 2022, EDPMA and ACEP sent a joint letter to the Departments of Health & Human Services, Labor, and Treasury providing feedback on the independent dispute resolution (IDR) Portal, which will be used to help facilitate claims through the federal IDR process under the No Surprises Act. The letter can be found here.

• Effective immediately, withdraw guidance documents that are based on, or that refer to, the portions of the Rule that the court invalidated. Once these documents have been updated to conform with the court’s order, we will promptly repost the updated documents.
• Provide training on the revised guidance for certified IDR entities and Disputing Parties. This training will be offered through webinars and roundtable discussions, and will occur after the above-referenced documents are updated.
• Open the IDR process for submissions through the IDR Portal. For disputes for which the open negotiation period has expired, the Departments will permit submission of a notice of initiation of the IDR process within 15 business days following the opening of the IDR Portal.

Importantly, the Departments note that all previous patient protections provided by the No Surprises Act remain in effect.

• The HHS guidance (via the Centers for Medicare and Medicaid Services) can be found here.
• The DOL guidance (via the Employee Benefits Security Administration) can be found here.

So far, EDPMA filed an amicus brief in three cases challenging the No Surprises Act rule implementing the independent dispute resolution process. Here is a related press release.

EDPMA has filed an amicus brief in a lawsuit filed in Texas by the Texas Medical Association, in the District of Columbia by the American Medical Association and American Hospital Association, and in Georgia by Georgia ACEP. EDPMA also plans to file an amicus brief in Illinois in the suit filed by ACEP.