The Centers for Medicare & Medicaid Services (CMS) has finally released its long-awaited No Surprises Act (NSA) Independent Dispute Resolution (IDR) Final Rule, introducing a series of changes that are meant to reshape how payers and providers navigate the NSA arbitration process – but does it actually address the underlying issues with the process? Not according to some.
Since the NSA IDR process began, dispute volumes and costs have far exceeded original projections, as you may have heard my colleagues and me say at least a few times.
The need for upgrades to the process have, at this point, become pretty obvious.
At the same time, the Trump Administration has really been aggressively promoting technology modernization across the federal government, whether that’s moving away from checks for all payments to and from the government or pushing payers and providers to electronic prior authorization. When viewed through that lens, the provisions of the Final Rule feel very consistent with the Administration’s broader approach.
That’s why one of the most important aspects of the Final Rule is the groundwork it lays for an enhanced federal platform to manage the IDR process, called the IDR Gateway.
The vision is to create a centralized online environment where all parties to a dispute can manage negotiations, initiate disputes, exchange notices, submit documentation, track deadlines, and communicate throughout the IDR process.
In many ways, it’s an effort to move the federal IDR program away from a patchwork of email and other manual processes and toward a more modern digital workflow.
The rule also expands the amount of information that health plans must provide with initial payments, to make it easier for providers to determine whether a claim qualifies for federal IDR and to reduce unnecessary administrative friction.
Certified IDR entities will now be required to determine whether a claim is eligible for the NSA IDR process within five business days after selection. New notice requirements, response timelines, and communication standards are intended to create greater consistency and accountability throughout the process.
Another headline change involves the basic cost to use the program. The administrative fee required to enter the federal IDR process will drop dramatically, to just $15 per party, per dispute. CMS hopes that lower fees, combined with more streamlined processes and improved technology, will make the system more accessible and efficient.
But while the rule does introduce meaningful operational and procedural changes, it’s important to take a look at what it does not do: CMS is focused on upgrading the infrastructure that supports the process, rather than fundamentally changing how the IDR process gets results. This leaves many of the issues providers and plans care about still in dispute.
The rule largely avoids addressing ongoing disputes surrounding the Qualifying Payment Amount, or QPA.
Providers have often stated that QPA calculations can significantly influence arbitration outcomes, and may not accurately reflect true market reimbursement rates. Plans believe that Congress specifically chose that as a key factor, and it’s an appropriate benchmark. Those conflicting viewpoints have been the subject of multiple lawsuits (we’re still awaiting a decision on TMA III), and they will likely remain a major point of contention between providers, payers, and regulators.
Similarly, the rule does little to address one of providers’ more practical issues of contention: collecting payment after winning an IDR determination. The Final Rule does not establish any new enforcement mechanisms or create a clear private right of action to collect unpaid IDR awards – another frequent-flyer argument in the courts.
So, this means that the litigation that has shaped much of the No Surprises Act’s implementation is likely to continue. CMS is improving how the process works, but not necessarily changing the underlying disputes that continue to drive conflict between providers and payers. So you’ll likely hear us continue to report on updates to the IDR process for many months to come!
