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1 1 (April 1, 2022)

handle is hein.crs/govefnn0001 and id is 1 raw text is: Congressional *.Research Service No Surprises Act's Independent Dispute Resolution Process and Related Litigation April 1, 2022 On December 27, 2020, the No Surprises Act (NSA), part of the Consolidated Appropriations Act, 2021 (P.L. 116-260), was enacted to address surprise billing (i.e., circumstances where individuals receive large, unexpected medical bills when they are unknowingly, and potentially unavoidably, treated by out- of-network providers). Surprise billing is rooted in most private insurers' use of provider networks, which generally results in consumers paying more for out-of-network care (relative to the same in-network care). The NSA established federal surprise billing requirements with respect to out-of-network emergency services, out-of-network nonemergency services provided during a visit at an in-network facility, and out- of-network air ambulance services. In these situations and for plan years beginning on or after January 1, 2022, the NSA generally limits the amount consumers pay for care and specifies a methodology used to determine how much insurers must pay providers for care, including the use of an independent dispute resolution (IDR) process. Taken together, these requirements effectively result in the provider and insurer recognizing the same total price for care. This Insight provides an overview of the NSA's IDR process; the Departments of Health and Human Services, Labor, and the Treasury's (tri-agencies') implementation of these requirements; and related litigation. The NSA's IDR Process and the Interim Final Rule Under the federal payment methodology, the insurer must make an initial payment (or notice of denial of payment) to the out-of-network provider for services rendered, after which either party may initiate open negotiations to attempt to reach an agreed-upon payment amount for services. If negotiations are unsuccessful, the parties may use the IDR process, which is a baseball-style arbitration process wherein the arbitrator chooses one of the parties' proposals to resolve the dispute. Under the IDR process, the provider and insurer each submit a proposed payment amount to the arbitrator and additional information relating to the submission. After considering specified criteria (discussed below), the arbitrator selects one of the two offers as the final payment amount, which is binding. This federal methodology would not apply in states with an all-payer model agreement or in situations addressed by a state surprise billing law payment methodology. Congressional Research Service https://crsreports.congress.gov IN11906 CRS INSIGHT Prepared for Members and Committees of Congress

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