No Surprises Act Information from CMS

A message from the American Medical Association:

Late this afternoon, the Centers for Medicare and Medicaid Services (CMS) circulated the following note. American Medical Association staff will evaluate the information and compare notes with our Federation colleagues.

New Rules

Most notably, today the Departments released final rules that account for the two district court rulings on the NSA and take into account comments from stakeholders to the interim final rules released last year. The rulemaking is narrow in scope, addressing specific issues related to disclosures by plans and issuers about the QPA and guidance for certified IDR entities on information to consider when they make payment determinations.

The new rule can be found here: https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/no-surprises-act

New FAQs

The Departments also issued a new set of FAQs providing guidance on several NSA requirements including how the law’s protections apply to no-network and closed-network plans, requirements related to disclosures, and the calculation of the qualifying payment amount, among other things. The new FAQs can be found here: https://www.cms.gov/files/document/faqs-part-55.pdf

Status Update on IDR and additional guidance

Finally, the Departments also released a brief status update on the federal IDR process. In short, many more disputes have been submitted to the federal IDR process than were initially anticipated. Additionally, certified IDR entities are conducting significant work determining whether a dispute is eligible for the federal process.

To help address this, on Tuesday we posted a new page on the CMS No Surprises Act website detailing some common mistakes and helpful tips for parties initiating IDR disputes. Our objective here is to help initiating parties get the certified IDR entities and non-initiating parties as much info on the front end as possible to help correctly determine eligibility and move disputes through the process. This also includes detailed technical guidance for the certified IDR entities on moving disputes through the process. While the guidance is technically for IDR entities, it’s publicly posted, and we think it could be helpful for disputing parties to keep in mind when they’re submitting information related to disputes.

We also rolled out some new functionality in the portal for initiating disputes. There’s now a dispute-level upload button which allows initiating parties to upload supporting documents to their disputes at initiation. We’re hopeful this will prevent delays in processing disputes by making sure that certified IDR entities have immediate access to documents like documents associated with the initial payment or notice of denial of payment (e.g., remittance advice or an explanation of benefits), notices of open negotiation initiation, extension requests, etc.