Biden Administration Releases New Guidance on QPA Calculations and Reopens the Portal for New Disputes
Claritev summarizes the FAQ issued by the Biden administration on October 6, 2023 as well as the reopening of the IDR portal.
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Two Federal Courts Make Rulings on NSA Challenges in Late August
Claritev summarizes changes to NSA regulations and guidance as a result of rulings in TMA3 and AAMS.
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NSA’s Final Rules
On August 19th, the long-awaited final rules under the No Surprises Act (NSA) were issued. Titled “Requirements Related to Surprise Billing: Final Rules,” they finalize certain requirements that group health plans and health insurance issuers offering group or individual health insurance coverage must meet when reimbursing claims determined to be surprise bills as defined by the Act.
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Tackling Out-of-Network Medical Bills with Data iSight
To tackle the problem of out-of-network charges, Claritev developed our Data iSight pricing methodology. Unlike Usual and Customary (U&C) or Medicare-based repricing solutions, our methodology recommends reductions using both a cost-up approach (for facility claims) and median reimbursement levels (for practitioner claims) to achieve maximum defensibility, wide provider acceptance, and savings of 61%-81% off billed charges.
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MultiPlan Acquires Leading Healthcare Data and Analytics Firm Benefits Science LLC
MultiPlan acquires Benefits Science Technologies—this acquisition will combine the capabilities of two leaders in the healthcare arena to provide cutting edge differentiated data and decision science solutions to customers across a full spectrum of channels and markets within the healthcare industry.
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Use of the IDR Process to Settle NSA Disputes Is Greater Than Anticipated
A little more than a year after launching the No Surprises Act’s Independent Dispute Resolution Portal, the Departments of Health and Human Services (HHS), Labor, and Treasury gave an update on the federal IDR process for the period from April 15, 2022 through March 31, 2023. Claritev highlights the findings.
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No Surprises Act Update: IDR Entities May Resume Issuing All Payment Determinations
IDR entities can once again issue payment determinations for No Surprises Act disputes following updated CMS guidance. After a temporary pause triggered by legal challenges to the IDR process, determinations resumed in phases—first for pre-October 25, 2022 services, and later for more recent claims—restoring momentum to dispute resolution between payers and providers.
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Certified IDR Entities Have Been Instructed to Hold All Payment Determinations Until Further Guidance Is Issued
CMS directed certified IDR entities to pause all payment determinations for No Surprises Act disputes following a February 2023 court ruling, requiring previously issued decisions to be recalled. While arbitration activities like eligibility reviews continued, the halt created delays and uncertainty as regulators worked to update guidance for compliant payment decisions.
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Determining Whether a Dispute Is Eligible for IDR Is Complicating the Process
More than a year after the No Surprises Act (NSA) took effect, parts of the law are still creating challenges, including the independent dispute resolution (IDR) process.
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Texas Medical Association Wins Its Second Suit Challenging the NSA’s IDR Process
On February 6, 2023, a federal judge in Texas ruled in favor of the Texas Medical Association (TMA) in their second suit challenging aspects of regulations related to the No Surprises Act’s Independent Dispute Resolution (IDR) process.