By Kevin B. O’Reilly, News Editor
The new federal law, which took effect in January of this year, bars surprise billing for emergency care and some nonemergency care at in-network facilities. The law and implementing regulations have established a process to determine payment for physicians, health care organizations and others that includes the IDR process.
The AMA’s new guide to the independent-dispute resolution process under the No Surprises Act (PDF) will be updated with the additional federal guidance that was released last week on disputing parties (PDF) and certified IDR entities (PDF). In addition, information on last week’s opening of a federal government-run online portal to manage the IDR process will be included.
Why it’s important: Implementation of the federal No Surprises Act, intended to protect patients from unanticipated medical expenses after receiving out-of-network care, is very much a work in progress.
After years of negotiations, the No Surprises Act was signed into law in late 2020 as part of the $1.4 trillion Consolidated Appropriations Act of 2021. While several iterations of the legislation were written, the AMA stood fast in advocating that the bill adhere to seven principles that called for insurer accountability and transparency while protecting patients and keeping them from getting caught in the middle of payment disputes. Read the AMA’s overview of the law (PDF).
The AMA’s IDR toolkit builds on a first guide helping doctors prepare the law’s implementation (PDF) and covers a number of essential questions, including:
- What constitutes a surprise medical bill for which balance billing is prohibited?
- Does the balance billing prohibition apply to certain health markets and not others?
- When does the federal IDR process apply, instead of a state payment methodology?
- What happens when state laws are narrower than the federal law?
- What does a physician practice do when it disagrees with an out-of-network payment from a health plan?
- When and how does a physician practice initiate the IDR process?
- Can IDR requests be batched to simplify the process?
- How is the final out-of-network payment made?
The toolkit also addresses the implications of ongoing litigation related to the IDR regulation and the changes made in response to a decision in a case filed by the Texas Medical Association.
Early this month, the AMA and the American Hospital Association urged the U.S. District Court for the District of Columbia to take quick action to vacate all the provisions of the No Surprises Act that they are challenging in the federal government’s interim final rule to implement the law.
About Kevin B. O'Reilly
Kevin rejoined the AMA in 2016 after an earlier stint as a senior reporter with American Medical News. He has covered a wide range of topics in health care, including diagnostics, medical ethics, quality improvement, patient safety and meetings of the AMA House of Delegates.
Most recently, Kevin served as senior editor at CAP Today, a monthly magazine published by the College of American Pathologists. He was graduated with honors from Columbia College Chicago’s print journalism program.