9-21-23 Update: TMA III & IV Ruling – How to Proceed

As of September 21^st 2023, CMS has released the following updates:

On August 24, 2023, the U.S. District Court for the Eastern District of Texas issued an opinion and order in Texas Medical Association, et al. v. United States Department of Health and Human Services, Case No. 6:22-cv-450-JDK (TMA III), vacating certain portions of 86 Fed. Reg. 36,872, 45 C.F.R. § 149.130 and 149.140 , 26 C.F.R. § 54.9816-6T and 54.9817-1T, 29 C.F.R. § 2590.716-6 and 2590.717-1, and 5 C.F.R. § 890.114(a) as well as certain portions of several guidance documents. As a result of the TMA III decision, effective immediately, the Departments have temporarily suspended all Federal IDR process operations until the Departments can provide additional instructions. Disputing parties should continue to engage in open negotiation.

The Federal Independent Dispute Resolution (IDR) process remains temporarily suspended. Disputing parties are unable to initiate new disputes. Effective September 5, 2023, certified IDR entities can resume determining eligibility and conflicts of interest (COI) for single and bundled disputes submitted on or before August 3, 2023. However, certified IDR entities should not update the Federal IDR portal with results of their eligibility and COI determinations in order to avoid triggering the Notice of Offer/offer submissions process, which remains on hold pending further guidance from the Departments. Certified IDR entities may reach out to disputing parties for any needed information in order to make a COI or eligibility determination. All other parts of the process remain on pause; parties should not be asked to pay fees or submit an offer in relation to any eligible disputes.

The latest update was sent on September 21^st, 2023:

Due to the TMA III court ruling on 08/24/2023, the Federal Independent Dispute Resolution (IDR) portal and all IDR web forms were temporarily unavailable.

This evening, Federal IDR portal access will be restored to certified IDR entities for all single and bundled disputes in the Notice of Offer or Payment Determination phases of IDR. It is critical that certified IDR entities follow the guidance below for resuming operations on 9/21/2023. 

• On 9/21/2023, certified IDR entities will be able to resume the regular Notice of Offer request and payment determination processes for single and bundled disputes that were initiated prior to 8/24/2023.
• Disputes where the Notice of Offer due date was on or between 8/24/2023 to 9/21/2023 will be granted a 10-business day extension. On 9/21/2023, the Federal IDR portal will send parties in these disputes’ emails reflecting the new deadline along with the Notice of Offer link. Certified IDR entities should grant 10-business day extensions for payments related to these disputes.
• On 9/21/2023, the Federal IDR portal will also send out the standard system-generated Notice of Offer emails for any disputes in which certified IDR entities made portal updates 9/7/2023 through 9/21/2023 to reflect the dispute is eligible for the Federal IDR process. 

The TMA III order vacated certain provisions of the regulation establishing the methodology for calculating the Qualifying Payment Amount (QPA). The Departments issued guidance on how to proceed with disputes following the court’s order,

[FHAS has also linked this guidance below for your convenience.]

Payment disputes between providers and health plans | CMS

With all of this new information entities are able to do the following:

Entity Capabilities:

• Able to resume the regular Notice of Offer request and payment determination processes for single and bundled disputes that were initiated prior to 8/24/2023.
• Sending invoices and links that were requested before the hold.
• Status Updates
• Processing withdrawals.
• Providing documents uploaded to the portal.

Entity Incapabilities:

• Reviewing any batched disputes.

Other important notes:

• Disputes where the Notice of Offer due date was on or between 8/24/2023 to 9/21/2023 will be granted a 10-business day extension. If you have an overwhelming number of disputes and 10-days is not enough time to submit all of your Notice of Offer forms, CMS has left it up to the entities to provide more time. If you believe you will need an extension in addition to the 10-day extension already received by CMS fill out the attached extension request and send to IDRE@fhas.com. Our team will review and get back to you with an approval or rejection.
  • CMS has not released guidance for disputes where the due date landed after August 3^rd, and before August 24^th. FHAS will send an inquiry for the disputes affected by this time frame.
• If you did not make payment due to the IDR process being put on hold, do so as soon as possible to avoid an Admin Closure or Default Determination in the opposing party’s favor.
• CMS has not released official guidance on how the entities are expected to weigh the QPA or forthcoming batching guidelines.

FHAS will continue to update you as we find out new information.

If you have questions feel free to email IDRE@fhas.com or call FHAS at (570) 779-5122 and ask for our IDR department. Thank you.