The U.S. Departments of Health and Human Services, Labor and the Treasury issued October 27, 2023 a comprehensive proposed rule that would modify the process for resolution of disputed out of network claims under No Surprises Act (NSA). WSHA plans to comment on the proposed rule by the January 2 comment deadline. The proposed rule has provisions that should streamline the process and make it easier for providers to determine if a claim is eligible for the independent dispute resolution (IDR) process. The proposed rule also should increase transparency regarding carriers.
WSHA is concerned and will comment regarding the proposal to limit batched claims to 25 claims. Also, while many of the proposed changes are of value, they do not address what are continuing major issues with the NSA’s IDR process. The proposed rule does not address the general lack of monitoring and enforcement regarding the qualifying payment amounts (QPA) offered by the carriers. This, along with CMS instructions to IDR entities that give inordinate weight and credibility to the QPAs offered by the carriers has undermined the process.
As a reminder, Washington State is continuing it own dispute resolution process under the state’s Balance Billing Protection Act through at least June of 2024. The BBPA process applies to state-regulated carriers (individual and small group) as well as self-funded groups that have elected to participate in the BBPA. The BBPA uses a “commercially reasonable” payment standard and market median payment amounts established through the state’s all payer claims database for its dispute resolution process. Hospitals and providers may want to consider if disputed out of network claims are eligible under the BBPA. More information is on the OIC Website. (Andrew Busz, email@example.com)