Radiology Coding Alert

No Surprises Act:

Will a 600% IDR Fee Increase Deter Radiologists From the Process?

Published on Tue Feb 21, 2023

Find out if batching requirements are too strict.

On Dec. 23, 2022, the Centers for Medicare & Medicaid Services (CMS) issued an amendment to the calendar year (CY) 2023 fee guidance for the Federal independent dispute resolution (IDR) process of the No Surprises Act (NSA). The amendment includes increases for administrative and certified IDR entity fees, which did not go unnoticed by healthcare professionals.

Learn how radiology practices are reacting to the IDR process changes.

Prepare to Shell Out More Cash to Dispute Claims

Effective Jan. 1, 2023, parties seeking IDR for disputes initiated during CY 2023 need to pay a $350 administrative fee. This fee is 600 percent higher than the $50 fee that CMS had originally set in place for 2023 on Oct. 31, 2022. The significant price hike wasn’t made on a whim. CMS notes the fee increase is “due to supplemental data analysis and increasing expenditures in carrying out the Federal IDR process since the development of the prior 2023 guidance” (www. cms.gov/cciio/resources/regulations-and-guidance/downloads/ amended-cy2023-fee-guidance-federal-independent-dispute-resolution-process-nsa.pdf).

“The fee for the IDR process just increased significantly for 2023. Part of that is CMS underestimated the amount of disputes that there would be, so there is a huge backlog right now. It’s kind of making sure that people are thinking through if their claim really applies to No Surprises Act and if the claim is eligible for the IDR process,” said Stacy Harper, JD, MHSA, CPC, partner at Spencer Fane in Overland Park, Kansas during AAPC’s REVCON 2023 session, “No Surprise Billing.”

In their first report on the IDR process, the U.S. Departments of Health and Human Services (HHS), Labor, and the Treasury, found that 90,078 disputes were submitted to the Federal IDR portal between April 15 and Sept. 30, 2022. The Departments initially estimated less than 20,000 claims would be submitted for an entire calendar year (www.dol.gov/sites/dolgov/files/ EBSA/about-ebsa/our-activities/resource-center/faqs/q2-and-q3- partial-report-121522.pdf).

Of the 90,078 submitted disputes, 23,107 disputes were closed. The reasons are as follows:

3,576 disputes received a payment determination
15,895 disputes were found to be ineligible
3,636 disputes were closed for other reasons

This leaves a backlog of 66,971 submitted disputes without a resolution. Also, with 15 percent of disputes reaching a payment determination and 69 percent of disputes deemed ineligible, the Departments collected a low amount of administrative fees compared to the overall volume of disputes in the portal. To cover the expenditures of the process, the Departments needed to establish an administrative fee that will match the costs needed to complete the process.

Recognize the Requirements Before Batching Your Disputes

“You can also batch similar claims to bundle them up. So, if you’re a radiologist and you’re doing 100 of these a day, you can batch them all together into one dispute process,” Harper said.

The NSA does allow multiple qualified services to be batched together into a single IDR process to promote efficiency. The Requirements Related to Surprise Billing; Part II, published to the Federal Register in October 2021, lays out the requirements to batch multiple claims together:

Services must be billed by a clinician with the same National Provider Identifier (NPI) or Taxpayer Identification Number
Payment for services must be made by the same payer (group health plan or health insurance insurer)
Services are billed under the same service code (or comparable code)
Services must be furnished within the same 30-business-day period (or same 90-calendar-day cooling off period)

(Source: www.federalregister.gov/documents/2021/10/07/2021- 21441/requirements-related-to-surprise-billing-part-ii)

Understand the Increase in Certified IDR Entity Fee Ranges

Certified IDR entities review the specifics of each dispute and determine the final payment amount if the parties involved are unable to reach an agreement in the 30-business-day open negotiation period. However, during 2022, the Departments found that “certified IDR entities incurred more administrative burden than originally anticipated.” As a result, the Departments sought to increase the fee ranges for certified IDR entities for single and batched determinations.

Below is a comparison of the certified IDR entity fees:

According to the Departments, the fee increases aim to reduce the costs of participating in the Federal IDR process to help protect consumers from shouldering the costs in the form of higher premiums. At the same time, the higher fees balance the “need for the certified IDR entities to be compensated for the entirety of their work” throughout the process. The Departments also feel the increased fee ranges “will fund a robust Federal IDR process and keep the volume of disputed claims manageable.”

Is Your Radiology Practice Feeling the Heat?

On Jan. 19, 2023, the American College of Radiology (ACR) issued an open letter to HHS Secretary Xavier Becerra, Labor Secretary Martin J. Walsh, and Treasury Secretary Janet Yellen responding to the substantial fee increases for the Federal IDR process. The ACR raised concerns that increased fees and narrow restrictions on batching may deter many clinicians and radiologists from using the IDR process.

“Most radiology claims are for less than $50, with the vast majority below $100. Almost none are $350 or more. Thus, without batching, radiology cannot access IDR in a cost-efficient manner,” wrote William T. Thorwarth Jr., MD, FACR, CEO of the American College of Radiology (ACR).

For example, Medicare pays an average of $9 for CPT® code 71045 (Radiologic examination, chest; single view). With the batching requirements and administrative fees, providers would end up paying more to enter the process than the desired outcome is worth.

The ACR did offer recommendations to the Departments, such as allowing clinicians to batch items and services under the same code categories (eg, 70000 CPT® code series) and withdrawing the fee increases set forth in the December 2022 amendment.

Stay tuned to Radiology Coding Alert for future No Surprises Act updates.