CMS declines to recertify credentials of two No Surprises Act arbitrators, citing performance standards
Two private arbitration companies have been denied recertification necessary for participation in dispute resolution related to the No Surprises Act, the Centers for Medicare & Medicaid Services (CMS) revealed on Wednesday.
The rejected applications for Island Peer Review Organization and Network Medical Review mean the two groups will no longer be eligible to adjudicate payment disagreements between healthcare insurers and providers, a process known as the Independent Dispute Resolution (IDR), set up strictly to manage conflicts related to out-of-network reimbursement for patient care.
Both companies have been involved in the IDR process since the beginning, settling thousands of billing conflicts under the terms of the No Surprises Act, which went into effect in 2022.
The law was designed to protect patients from receiving an unexpected bill for medical services, oftentimes linked to situations where they inadvertently or necessarily receive out-of-network care, triggering a dispute between healthcare payers and providers that cannot be immediately solved, due to the lack of a pre-existing reimbursement contract.
IDR arbitrators are then tasked with deciding what a fair rate for payments would be, based on input from the insurance company and providers alike.
As for why Island Peer Review and Network Medical Review were denied recertification—something all participants must reapply for every five years—CMS didn’t provide many specifics, but did make a statement about the standards the agency expects from all its private arbitrators.
“Certified IDR entities play a critical role in the federal IDR process. The No Surprises Act charges them with issuing timely and impartial payment determinations when healthcare providers, facilities, or providers of air ambulance services and health plans or issuers are unable to agree on an out-of-network payment amount through open negotiation,” CMS wrote. “To remain certified, IDR entities must continue to meet the standards for certification set out in the NSA and regulations, including requirements related to timeliness, accuracy, and independence and impartiality in making payment determinations.”
The agency went on to confirm that Island Peer Review and Network Medical Review “did not meet minimum performance standards and are therefore not eligible for recertification as certified IDR entities.”
Other applications for recertification are still pending, and CMS said its decision not to renew contracts with these two entities will not impact future recertifications.
As Island Peer Review and Network Medical Review are still operating as part of the IDR and have cases pending, CMS said it will be issuing “further guidance” in the near future to stakeholders outlining next steps to have their disputes resolved.
Those with questions are advised to contact CMS at the email address provided in its notice, which can be found by clicking here.
NSA arbitration under scrutiny
In June, the Congressional Budget Office released a report, finding that early data shows providers are heavily favored in IDR disputes, beating healthcare payers about 80% of the time. Further, the government accountability watchdog said evidence that the No Surprises Act is reducing the cost of care for consumers is currently lacking.
Questions have also been raised about how effective the IDR is, given that decisions made by arbitrators lack teeth. In September, a federal court declined to intervene after Cigna refused to pay a $3 million dispute resolution award, accusing a provider group of failing to submit proper documentation for reimbursement claims.
Some lawmakers would like to see the IDR eliminated entirely, in favor of a blanket policy that aligns out-of-network reimbursement with in-network rates. To that end, a Democrat in the U.S. House of Representatives introduced the “Lower Premiums, Faster Payments Act” that, if passed, would totally eliminate the arbitration process starting in 2027.
That bill, introduced in October, has so far failed to gain any traction.
Chad is an award-winning writer and editor with over 15 years of experience working in media. He has a decade-long professional background in healthcare, working as a writer and in public relations.