Employer health plans that pay out-of-network doctors or hospitals less than the providers billed now have to tell the providers exactly what plan is paying the bill.
A plan that “downcodes” a claim must also give the provider some information about why it downcoded the claim.
The new claim payment message requirements took effect last week. They are just some of the new requirements that are taking effect as federal regulators revamp the federal No Surprises Act independent dispute resolution system.
The federal agencies in charge of the IDR system — including teams at the U.S. Department of Health and Human Services, the U.S. Labor Department, the U.S. Treasury Department and the U.S. Office of Personnel Management — talk about the new downcoding message requirements in an IDR system reboot implementation timeline notice that was posted Friday.
The No Surprises Act IDR system: The IDR system is supposed to protect commercial health plan participants who follow plan rules against “surprise bills” for some types of out-of-network care.
Payers and providers are supposed to take claim fights over the care to “IDR entities” and leave the patients out of the fights.
Employers, health insurers and employer plan administrators have founded that the IDR entities rule in favor of the providers most of the time and award the providers amounts that are often much higher than what the providers would have received for providing the same care for a health plan’s in-network patient.
The federal agencies in charge of the IDR system have promised to replace the current system by moving it onto a an IDR Gateway, or federal No Surprises Act claim dispute platform.
The new system is also supposed to include new rules for how the parties start claims and a chance for members of the public to comment on the services of IDR entities that want to continue to be IDR entities.
What’s in effect now: New interim final regulations cut the administrative fees that parties must pay regulators to start a dispute to $15 per party per dispute, from $115, in June, officials say in the new implementation timeline.
The new downcoding message rules were just some of the new rules that took effect last week.
Other new rules now require providers to pay IDR administrative fees and IDR entity fees promptly to keep disputes alive.
What it means: Executives from Aetna and UnitedHealth have told investors in recent weeks that IDR is one of the reasons commercial health coverage rates are skyrocketing.
Federal agencies may have posted the new IDR Gateway implementation timeline to show that they have heard payers’ concerns and are trying to work quickly to replace the current IDR system.