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EDPMA and ACEP Meet with CMS/CCIIO Staff To Advocate For You
Re: Implementation of the No Surprises Act
EDPMA’s members consistently report that health plans are not providing federally required information to bill patients’ out-of-network services and to proceed with the federal Open Negotiations and Independent Dispute Resolution (IDR) processes that are part of the No Surprises Act. To advocate on your behalf, we wrote a letter to federal agencies last month that provided: 1) specific examples of health plan non-compliance; and 2) policy recommendations that would help address these non-compliance issues. EDPMA thanks our members who shared their redacted data to support this advocacy effort.
Last week, EDPMA and ACEP met with the Center for Consumer Information and Insurance Oversight (CCIIO) at the Centers for Medicare & Medicaid Services (CMS) staff to follow-up on our letter. During the meeting, we described to CCIIO what specific health plan non-compliance issues we are experiencing, provided specific recommendations, and also requested additional guidance on how we should proceed with the Open Negotiations and IDR processes when there is limited or missing information from health plans (information that was required by the first interim final rule implementing the No Surprises Act). We also emphasized the critical need for strong enforcement to ensure health plans provide information as required by law.

CCIIO made two important points about complaints:
  • If a complaint remains unresolved and the timelines around the Open Negotiation and IDR processes become difficult to adhere to, disputing parties can file for an extension.
  • As outlined in the IDR guidance (page 29), you file for an extension due to extenuating circumstances by emailing a Request for Extension due to Extenuating Circumstances to FederalIDRQuestions@cms.hhs.gov.
  • We explained to CCIIO that this solution is not optimal for providers since it delays when they would receive an appropriate payment from health plans, and it allows health plans to keep funds that they owe to providers. 
  • You are allowed to “batch” complaints against one health plan. In other words, instead of submitting a complaint for each individual claim, you can submit all the complaints against one health plan at once. This may help save time and speed up the time in which your complaints are processed and adjudicated by CMS.
CCIIO staff stated that they heard many of these issues before and have received many complaints from providers that health plans are not providing all the required information. CCIIO also claimed they resolved about 25% of all complaints, and there is a significant backlog of unresolved complaints. Further, they stated that when a complaint is resolved, they request documentation from the health plan and continue to work with them to systematically resolve similar complaints moving forward. While CCIIO confirmed they are hosting internal conversations about how to enforce non-compliance, they did not offer specifics on enforcement processes or outcomes.
We believe the meeting was productive and we are reassured that CCIIO is acutely aware of these issues and is taking them seriously. Because CCIIO did not commit to adopting our policy recommendations, we will continue to follow-up with CCIIO on these requests.

As always, EDPMA has your back by advocating on your behalf and providing the resources you need to manage a successful business.

As a reminder, you can submit billing complaints by clicking here or by contacting the No Surprises Help Desk at 1-800-985-3059.