No Surprises Act
Understanding the Federal Independent Dispute Resolution (FIDR) Program
The Federal Independent Dispute Resolution (FIDR) program, established under the No Surprises Act (part of the Consolidated Appropriations Act, 2021), serves as a framework for resolving disputes between payers, facilities, and care providers over out-of-network payments. Managed by the Centers for Medicare & Medicaid Services (CMS), the program aims to protect patients from unexpected medical bills stemming from out-of-network services, particularly in emergencies or at in-network facilities.
While Stratus is not yet certified as an Independent Dispute Resolution Entity (IDRE), we are actively preparing by staying informed of FIDR updates, including interim and final rules. Our team, composed of highly credentialed healthcare lawyers, is dedicated to engaging with stakeholders to ensure readiness for the smooth adoption of new FIDR requirements and processes upon approval.
Here's a detailed breakdown of the CMS Federal IDR program
Purpose
The primary objective of the Federal IDR program is to address and resolve payment disputes between health plans and providers, facilities, or air ambulance services for certain out-of-network charges without involving the patient directly.
Scope
The program specifically applies to:
01
Emergency Services: When a patient receives emergency services from an out-of-network provider or facility.
02
Non-Emergency Services: When a patient receives non-emergency services from an out-of-network provider at an in-network facility.
03
Air Ambulance Services: When a patient receives services from out-of-network air ambulance providers.
Process
Key Steps of the Process:
01
Initiation: Either the health plan or provider/facility may initiate the IDR process if they cannot agree on the payment amount (QPA).
02
Submission: Both parties submit their best and final offers for the payment amount, along with supporting documentation, to the IDRE.
03
IDRE Selection: Stratus (pending certification) or another CMS-authorized IDRE serves as the impartial third party to oversee the dispute resolution process.
04
Decision: The IDRE evaluates both submissions and selects one of the offers without modification, following the criteria outlined in the regulations. This approach is known as “baseball-style arbitration.”
05
Binding Decision: The decision rendered by the IDRE is binding on both parties, ensuring compliance and resolution.
Timeline
The Federal IDR process prioritizes efficiency, with strict timelines to ensure disputes are resolved promptly. This design helps avoid prolonged disagreements and ensures quick outcomes for both parties.
Fees
- Both parties are responsible for fees associated with initiating the process and IDRE services.
- Refunds for Prevailing Party: The prevailing party in the dispute will have their arbitration costs reimbursed.
- Non-Refundable Administrative Fees: Administrative fees paid to CMS are non-refundable.
- Stratus Fee Structure: Stratus, upon certification, will charge fees aligned with CMS standards, reflecting the premium quality and reliability of its services in the program.
Compliance and Transparency
CMS monitors the process to ensure compliance with the regulations and maintains transparency. This includes publishing regular reports on the overall use and outcomes of the IDR process.
Impact on Patients
One of the key benefits of the Federal IDR program is that it insulates patients from the financial disputes between insurers and providers. Patients are only responsible for paying their in-network cost-sharing amounts as determined by their health plan, freeing them from additional charges stemming from out-of-network billing practices.
Summary
The CMS Federal Independent Dispute Resolution program thus plays a crucial role in mediating billing disputes, fostering fair payment practices, and most importantly, protecting patients from surprise medical bills. It represents an important step toward greater transparency and equity in health care billing practices.
Stratus is committed to delivering exceptional IDR services upon certification, ensuring fairness, efficiency, and compliance throughout the dispute resolution process.