CMS Proposes Stricter Requirements for Payers Under No Surprises Act 

01 Nov, 2023 F.J. Thomas


Sarasota, FL ( - Earlier this year, testimony presented to the House Committee on Ways and Means, showed that the number of healthcare provider bankruptcies increased 84 percent from 2021 to 2022. Although workforce shortages paired with increased operating costs is certainly a factor, the No Surprises Act was listed as a primary contributor due to the decreased revenue and delays in payment. 

The No Surprises Act was signed into law in 2020, as part of the Consolidated Appropriations Act of 2021. The basic purpose of the law was to address gaps in insurance coverage when patients unknowingly obtain healthcare services outside of their network, especially in emergent scenarios. Under the act, providers and payers were offered the opportunity to resolve out of network pricing and payment disputes for 30 days. After the 30 days, if an agreement was not reached either party could initiate the federal Independent Dispute Resolution (IDR) process, for a fee. 

As no surprise to providers, the IDR process has had multiple delays as the system was initially overwhelmed with the number of cases, in addition to the lawsuits that followed. 

Revealed Oct. 27, CMS announced proposed rule changes to the No Surprises Act in their effort to improve the functioning of the IDR process. CMS states the changes would facilitate and shorten communications between payers, providers, and certified IDR entities, and help the program to be more efficient. 

Under the proposed changes, payers would be under stronger requirements than previously. The new rules would require payers to provide specific claim adjustment reason codes (CARCs) and remittance advice remark codes (RARCs) to any provider that is not contracted. Additionally, payers would be required to provide their legal business name of the plan, business name of the plan sponsor, and its IDR registration number. According to the announcement, this requirement was the result of difficulties of providers in communicating and obtaining key information necessary to resolve payment disputes.

Another change proposed is the implementation of a 30-business day open negotiation time period where both parties have the opportunity to agree on fair payment without resorting to the full IDR process and paying the resulting fee. The proposal would require a response notice to be sent by the receiving party by the 15th day. CMS states the changes would create more certainty around start and end dates of disputes, as well as reduce the number of ineligible disputes.

Certified IDR entities would have 5 business days to determine the eligibility of a dispute request filed through the IDR. Additionally, both payers and providers would have 5 business days to provide additional requested information. 

Batching of issues filed through the IDR process is another proposed change. The proposed limit would be 25 qualified IDR items or services filed in a single dispute. 

Under the new proposals the administrative fee would remain, however the fee would be collected directly from both disputing parties. The initiating party would be required to pay the fee within 2 business days, and the other party would be required to pay within 2 business days of eligibility determination. Additionally, non-initiating parties would pay a reduced fee if the complaint was found to be ineligible. 

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    About The Author

    • F.J. Thomas

      F.J. Thomas has worked in healthcare business for more than fifteen years in Tennessee. Her experience as a contract appeals analyst has given her an intimate grasp of the inner workings of both the provider and insurance world. Knowing first hand that the industry is constantly changing, she strives to find resources and information you can use.

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