Dive Brief:

  • The online portal for resolving payment disputes between payers and providers for certain out-of-network charges is now open, the CMS said Monday. The portal initiates what’s known as the federal independent dispute resolution process, a key part of the No Surprises Act that outlaws balance bills in most cases. As a last resort, it allows payers and providers to resolve payment disputes using an arbitration style similar to the model adopted by Major League Baseball in salary negotiations.
  • A federal court ruling in February threw a wrench in plans to open the portal. The Texas judge’s ruling invalidated a specific part of the law pertaining to the dispute resolution process, forcing regulators to pull back guidance for third-party arbiters and delaying the opening of the portal.
  • The CMS has posted revised guidance for independent arbiters, providing instructions on the factors and information they must consider before picking an offer.

Dive Insight:

The No Surprises Act has been hailed by some healthcare-patient advocacy groups as it protects consumers against most unexpected medical bills.

Still, how the Biden administration chose to implement a piece of that law has sparked controversy among some providers who claim it tips the scales in favor of insurers.

Providers have taken issue with the arbitration process outlined in an interim rule, which has resulted in numerous lawsuits from various provider groups, including the American Hospital Association and the American Medical Association.

The interim final rule instructed third-party arbiters to start with the presumption that the qualifying payment amount, or median in-network rate, is the appropriate payment amount for providers when disputes between payers and providers arise.

A federal judge sided with providers in their lawsuit and struck down this piece of the rule, noting that the law as written by Congress, unlike the rule, didn’t “weigh any one factor … more heavily than the others.”

That ruling forced regulators to pull back guidance for arbiters online and delay the opening of the portal.

The revised guidance online does not instruct arbiters to begin with the presumption that the qualifying payment amount is the correct amount. However, it does outline what arbiters must consider in choosing an offer amount from either the payer or providers. The arbiter must consider the qualifying payment amount and additional credible information, according to the guidance.

Katie Keith, a lawyer and health policy expert at Georgetown University, told Healthcare Dive the updated guidance is “consistent with the statute.”

Sean Barry, a spokesperson for the American Hospital Association, declined to comment on the revised guidance.