The DOL, HHS, and IRS have collectively issued a report with utilization information on the shock billing unbiased dispute decision (IDR) course of created when the Consolidated Appropriations Act, 2021 (CAA, 2021) expanded affected person protections to defend people from shock payments for sure out-of-network emergency and non-emergency companies. The CAA, 2021 and rules addressing procedural features of plan funds to nonparticipating suppliers, together with the function of licensed IDR entities, require the companies to publish quarterly studies highlighting IDR exercise (see our Checkpoint article). The information for the studies is drawn from licensed IDR entities and the HHS federal IDR portal, which opened April 15, 2022 (see our Checkpoint article).

The companies have launched a report representing two quarters of information from April 15–September 30, 2022. Notably, disputing events initiated 90,078 disputes via the IDR portal, however solely 23,107 had been closed through the interval, usually due to processing delays when events contested their disputes’ eligibility for the federal IDR course of. Of the closed disputes, over two-thirds of these referring to emergency and non-emergency companies had been discovered ineligible for the federal IDR course of, and practically half of closed air ambulance disputes had been discovered ineligible. Explaining that eligibility is determined by a number of elements, together with figuring out state versus federal jurisdiction, right batching and bundling, compliance with relevant time intervals, and completion of open negotiations, the report factors out that 22 states have state legal guidelines that shield shoppers from shock billing and supply a technique for figuring out the cost quantity in sure circumstances. A desk itemizing disputes initiated by state reveals that 60% of all disputes had been initiated in Texas, Florida, Georgia, Tennessee, and North Carolina, regardless of Texas, Florida, and Georgia having a state course of that might apply to cost disputes of sure gadgets and companies. One other desk that tracks disputes by the companies supplied based mostly on Present Procedural Terminology (CPT) codes signifies that the most typical CPT codes concerned in disputes had been emergency division service codes (66% of disputes), radiology codes (9% of disputes), and anesthesia codes (7% of disputes).

EBIA Remark: The companies state that this preliminary, partial report was delayed as a result of events submitted considerably extra disputes than the companies initially estimated, and the IDR portal’s reporting performance required substantial guide processing. The IDR administrative charge was elevated for 2023 to mirror the rising quantity of disputes and extra expenditures related to the companies’ enhanced function in conducting pre-eligibility evaluations to deal with a rising backlog of disputes (see our Checkpoint article). For extra info, see EBIA’s Well being Care Reform guide at Sections XII.B.3 (“Shock Medical Billing: Emergency and Non-Emergency Companies”) and XII.B.4 (“Shock Air Ambulance Billing”) and EBIA’s Group Well being Plan Mandates guide at Part XIII.B (“Affected person Protections”). See additionally EBIA’s Self-Insured Well being Plans guide at Part XIII.C (“Federally Mandated Advantages”).

Contributing Editors: EBIA Workers.