News Releases

Surprise Billing Payment Determinations Resume

On Feb. 24, the Centers for Medicare and Medicaid Services (CMS) instructed federal independent dispute resolution (IDR) entities to resume processing surprise billing payment determinations beginning on Feb. 27 for disputes involving items or services furnished before Oct. 25, 2022.

This follows a Feb. 6 decision by a federal court in Texas that concluded the revised IDR process skews the arbitration results in commercial insurers’ favor in violation of the compromise Congress reached in the No Surprises Act. In the decision, the court vacated provisions in the surprise billing final rule that violated billing regulations governing how payment amounts are determined when disputes between providers and payers regarding out-of-network payments go to arbitration. This included a provision known as the qualifying payment amount which gives added weight to the median in-network rate.

Following the Texas court’s decision, CMS instructed arbitrators to stop making payment determinations until CMS issues further guidance and to recall any payment determinations issued after Feb. 6, 2023, the date of the Texas court decision.

According to CMS, Certified IDR entities should continue to hold issuance of payment determinations for services furnished on or after October 25, 2022, as it works to complete necessary guidance and system updates to allow these to proceed. This hold will continue until the departments of Health and Human Services, Labor, and the Treasury issue further guidance.

All additional federal IDR process timelines remain valid. Consequently, disputing parties should continue to engage in open negotiations and all other aspects of the federal IDR process, including submitting fees and offers.

The No Surprises Act took effect on Jan. 1, 2022, and requires insurers and providers that fail to agree on rates for out-of-network care to engage in independent dispute resolutions overseen by arbitrators. CMS unveiled the federal mediation portal in April 2022.