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No Surprises Act: Dispute Resolution Proposed Changes and 2024 Fee Increase

March 8, 2024

Leigh Polk

Sr. Account Based Marketing Manager

The No Surprises Act, enacted on January 1, 2022, established new federal protections against surprise medical bills and balance billing for services received from out-of-network providers.

Its purpose is to shield patients from unexpected out-of-network medical expenses incurred during:

  • Emergency room visits
  • Air ambulance services
  • Non-emergency care received at, or provided in conjunction with, a visit to an in-network hospital, hospital outpatient department, or ambulatory surgical center

However, nearly two years after its enactment, the No Surprises Act continues to be entangled in a complex web of regulatory, legal, and operational challenges.

The majority of the controversy surrounding the No Surprises Act has been related to the independent dispute resolution (IDR) process, which allows disputing parties to resolve disagreement regarding payments. In addition to multiple lawsuits challenging the IDR process, CMS has received substantially more disputes than anticipated leading to confusion and delays.

Over 300,000 surprise billing disputes were initiated through the federal IDR process from April 2022 through March 2023, which far exceeds the department’s original estimated caseload.

Out-of-Network Surprise Billing Disputes Initiated through the Federal IDR Process

April 15, 2022 through March 31, 2023
Source: CMS Federal IDR Process Update

CMS indicates a frequent cause of dispute processing delays is the difficulty in determining if the dispute is eligible for the IDR process. As a result, in October 2023, CMS released proposed changes to the IDR process to improve operations and timely payment determinations.

Key changes to the process from the proposed rule include:

Mandating payors to utilize a standardized code to indicate whether a claim from an out-of-network provider is eligible for the federal IDR process.
Parties opting for open negotiations must utilize the IDR portal to issue an open negotiation notice, alongside providing the other party and the federal departments with a copy of the remittance advice or denial of payment notice.
The proposal mandates the receiving party to furnish an open negotiation response notice by the 15th day of the 30-business-day open negotiation period.
Specifying the categories of qualified IDR items and services to be batched, including:

    • Items and services furnished to a single patient on one or more consecutive dates of service and billed on the same claim form (a single patient encounter)
    • Items and services billed under the same service code or a comparable code under a different procedural code system
    • Anesthesiology, radiology, pathology, and laboratory items and services billed under service codes belonging to the same Category I CPT code section, as specified in guidance by the Departments, to address the unique circumstances of these medical specialties and provider types
Restricting batched determinations to 25 qualified IDR items and services per dispute to ensure timely eligibility and payment determinations by certified IDR entities.
Requiring certified IDR entities to determine eligibility within five business days of final selection and notify both disputing parties and the Departments, with provision for additional information submission within five business days upon request.
Streamlining fee collection by directly collecting nonrefundable fees from disputing parties within two business days, implementing reduced administrative fees for both parties when the highest offer made during open negotiation falls below a predetermined threshold, and charging the non-initiating party a reduced administrative fee in ineligible dispute cases.

In addition to the proposed changes outlined above, CMS also released the 2024 IDR fees, which are increasing as a result of the significant backlog of cases. The administrative fee increase was mitigated by the Texas Medical Association lawsuit victory in 2023, challenging how the IDR process is administered and how fees are assigned. As a result, it was determined that a fee of $115 per party per dispute was appropriate. This decision was reached after recognizing that a fee of $50 was insufficient to cover the operational expenses of the IDR process and portal, while a fee of $350 posed financial challenges for providers.

2024 IDR Fees


For additional information on the No Surprises Act, visit XiFin’s No Surprises Act Resource Center, which includes FAQs, Complimentary Webinars, NSA industry news, and resources from industry experts.

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