No Surprises Act Archives - HEALTH & LIFE SCIENCES NEWS

HHS, DOL and Treasury Issue a Proposed Rule Increasing Federal IDR Fees

by Jamie Gelfman, Drew McCormick and Emily Curran | Oct 3, 2023 | Hospitals & Health Systems, Managed Care

On September 20, 2023, the US Departments of Health and Human Services (HHS), Labor (DOL) and the Treasury (collectively, the departments) issued a proposed rule related to the No Surprises Act’s (NSA’s) federal independent dispute resolution (IDR) process. The proposed rule would amend existing regulations to provide that the two fees associated with the IDR process—the administrative fee amount charged by the departments, and the ranges for the IDR entity fees for single and batched determinations—be established by the departments through notice and comment rulemaking. The proposed rule outlines the methodology for calculating the fees and proposes the fees/fee ranges for disputes initiated on or after January 1, 2024. The proposal comes in response to a court order in the recent Texas Medical Association (TMA IV) case, which requires the departments to establish such fees through formal rulemaking.

IN DEPTH

ADMINISTRATIVE FEE TO INCREASE TO $150

The NSA’s nonrefundable IDR administrative fee is paid by both parties to cover the cost of their participation in the IDR process. For 2022, the administrative fee was $50 per party. The fee was expected to remain the same for 2023. However, in December 2022, the departments issued revised guidance increasing the fee from $50 to $350 for 2023. Plaintiffs in TMA IV challenged the increase as being unlawfully issued via guidance. The US District Court for the Eastern District of Texas agreed and vacated the portion of the guidance that increased the fee.

In light of the court’s order, the [...]

Continue Reading

PPM ASC Symposium 2023 | State of the PPM Industry: Perspectives from Top CEOs

by McDermott Will & Emery | Jun 12, 2023 | PPM/ASC

During this session, Partner Jerry Sokol moderated a panel in which top CEOs shared their insights on capitalizing on opportunities and overcoming obstacles in the current environment. They discussed the transition to value-based care, the No Surprises Act (NSA), physician alignment and the future of the physician practice management (PPM) deal landscape, among other topics.

Session panelists included:

Bob LaGalia, President & CEO, Unified Women’s Healthcare
James Swift, MD, CEO, Pediatrix Medical Group, Inc.
Corina Tracy, CEO, U.S. Urology Partners
James Weber, MD, CEO, GI Alliance
Rich Whitney, Founder, Chairman & CEO, Radiology Partners

Top takeaways included:

Value-Based Care.
- At this time, industry players are focused on building capabilities to ensure they are ready for the transition to value-based care. Changes to payment programs may take a long time, but using this time to prepare and focus on adding value can help with long-term success.
- One of the biggest challenges platforms face when adopting value-based care models is physician engagement. Strategies for enhancing engagement include aligning economic incentives (while protecting physicians from risk) and investing in the right technology infrastructure and tools to support value-based care delivery.
- Data aggregation and actuarial analysis are critical to success in a value-based environment. Providers and platforms need to understand the historical costs, treatment patterns, and other characteristics of their patient population and carefully assess the financial implications of a value-based care arrangement before making the jump.
- Payors are not always ready for value-based care, even when platforms and providers [...]
  
  Continue Reading

Departments Release Update on No Surprises Act Independent Dispute Resolution Process

by Brian Stimson and Emily Curran | Apr 28, 2023 | Hospital Health Benefits, Hospitals & Health Systems

On April 27, 2023, The Departments of Health and Human Services (HHS), Labor, and the Treasury (the Departments) released a status update on the Federal Independent Dispute Resolution (IDR) Process, which covers the period from April 15, 2022 through March 31, 2023, as well as the initial report on the fourth quarter of 2022. Below are some of the key statistics shared.

Status Update

Between April 15, 2022 and March 31, 2023, 334,828 disputes were initiated through the Federal IDR portal. This caseload is 14 times greater than what the Departments initially anticipated.
- Non-initiating parties challenged the eligibility of 122,781 of the disputes and nearly 40,000 were deemed ineligible and closed.
IDR entities have rendered payment determinations in 42,158 disputes to date.
Initiating parties have been the prevailing party in ~71% of the disputes.

Fourth Quarter Report

During Q4 2022, disputing parties initiated 110,034 disputes through the Federal IDR process. This represented a 53% increase over Q3.
IDR entities made over three times more payment determinations in Q4 compared to Q3. IDR entities also closed fewer disputes as ineligible during Q4. Non-initiating parties challenged 40% of the disputes initiated.
Over two-thirds of the disputes submitted to the Federal IDR portal involved items or services furnished in bifurcated states (i.e., states where some items/services may be subject to a specified state law or All-Payer Model Agreement).
The report includes a summary of the Top 10 Initiating and Non-Initiating Parties.