Access to Care

How doctors can use No Surprises Act to resolve billing disputes

Kevin B. O'Reilly , Senior News Editor

What’s the news: The AMA has assembled a toolkit to help physicians navigate the new independent-dispute resolution (IDR) process under the No Surprises Act. An April 21 AMA webinar will offer more expert insight on the out-of-network payment process under the law. Register now.

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The new federal law, which took effect in January of this year, bars surprise billing for emergency care and some nonemergency care at in-network facilities. The law and implementing regulations have established a process to determine payment for physicians, health care organizations and others that includes the IDR process. 

The AMA’s new guide to the independent-dispute resolution process under the No Surprises Act (PDF) will be updated with the additional federal guidance that was released last week on disputing parties (PDF) and certified IDR entities. In addition, information on last week’s opening of a federal government-run online portal to manage the IDR process will be included.


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No Surprises Act: Expert insights to help doctors follow the law

Why it’s important: Implementation of the federal No Surprises Act, intended to protect patients from unanticipated medical expenses after receiving out-of-network care, is very much a work in progress.

After years of negotiations, the No Surprises Act was signed into law in late 2020 as part of the $1.4 trillion Consolidated Appropriations Act of 2021. While several iterations of the legislation were written, the AMA stood fast in advocating that the bill adhere to seven principles that called for insurer accountability and transparency while protecting patients and keeping them from getting caught in the middle of payment disputes. Read the AMA’s overview of the law (PDF).

The AMA’s IDR toolkit builds on a first guide helping doctors prepare the law’s implementation (PDF) and covers a number of essential questions, including:

  • What constitutes a surprise medical bill for which balance billing is prohibited?
  • Does the balance billing prohibition apply to certain health markets and not others?
  • When does the federal IDR process apply, instead of a state payment methodology?
  • What happens when state laws are narrower than the federal law?
  • What does a physician practice do when it disagrees with an out-of-network payment from a health plan?
  • When and how does a physician practice initiate the IDR process?
  • Can IDR requests be batched to simplify the process?
  • How is the final out-of-network payment made?

The toolkit also addresses the implications of ongoing litigation related to the IDR regulation and the changes made in response to a decision in a case filed by the Texas Medical Association.  

Early this month, the AMA and the American Hospital Association urged the U.S. District Court for the District of Columbia to take quick action to vacate all the provisions of the No Surprises Act that they are challenging in the federal government’s interim final rule to implement the law.

Read up on the litigation and find out why President Biden’s surprise-billing rule is not the law that Congress passed.

Related Coverage

The No Surprises Act is in effect. What physicians need to know.

Learn more: As a follow-up to the AMA’s January webinar on the No Surprises Act, a webinar set for April 21, 11:30 a.m. CDT, will focus on the payment process for physicians in surprise medical billing situations. Joel Ario and Michael Kolber from Manatt Health will join Bobby Mukkamala, MD, chair of the AMA Board of Trustees, to discuss provisions of the law, such as the initial payment, open negotiations period and the IDR process.

The speakers will also discuss the different ways that state regulators are choosing to enforce the law’s surprise-billing provisions, including in those states that have surprise medical billing laws. There will be time for questions and answers. Register now.