The Centers for Medicare & Medicaid Services (CMS) has opened the federal independent dispute resolution (IDR) process portal.
The IDR process can be initiated to resolve payment disputes between health care providers and issuers. At the end of the open negotiation period, initiating parties have four business days to initiate a dispute via the portal. Even after starting the federal IDR process, disputing parties can continue to negotiate until the IDR entity makes a determination.
However, CMS has yet to release new guidance after a federal court decided CMS was mistaken to instruct IDR entities to make the qualifying payment amount (QPA) the primary factor in determining payment for out-of-network services. Per regulations, the IDR entity must consider the QPA, information the entity requests, and the following factors, if the information is considered credible:
- the provider’s level of training, experience, and quality and outcomes measures;
- market share of the provider or issuer;
- acuity of the patient;
- teaching status, case mix, and scope of services; and
- demonstration of good faith efforts to enter into network agreements.
Finally, CMS released a list indicating whether the federal IDR process applies in each state. Twenty-eight states and the District of Columbia will be required to use the federal IDR process, 18 states will use a bifurcated process, and four states should use their states’ IDR process.
Contact Senior Director of Policy Erin O’Malley at email@example.com or 202.585.0127 with questions.