As discussed in our recent blog, federal regulations governing the Independent Dispute Resolution (IDR) process could be finalized imminently, now that the Proposed Federal IDR Operations Rule is under review at the Office of Management and Budget (OMB).
The IDR process has seen strong and growing volumes. Backlogs have fallen dramatically, per federal data. Still, FHAS continues to see eligibility errors, many of them involving batched claims. The proposed rule contemplates significant changes to the batching regulations, so in this post we’ll take a closer look at those changes. Providers or plans with questions should reach out to us for clarity and support.
“Unrivaled communication, education, and process support are the hallmarks of FHAS’s fair and transparent IDRE service,” said Jim Bobeck, FHAS CEO. “Parties are encouraged to talk to us about their account and have focused one-on-one discussions about how to avoid pitfalls in batching or any other area that can delay or disrupt the process or force an ineligibility ruling.”
“As stakeholders in the IDR process, we continue to monitor the release of the final rules. FHAS is prepared to provide you with information and perspectives that will help your organization implement changes to the process,” Bobeck added.
Why Change Batching Regulations?
The law and subsequent regulations by the U.S. Departments of Health and Human Services (HHS), Labor, and the Treasury enabled “batching” certain claims together under one dispute, rather than having to arbitrate – and pay fees for – each claim individually.
Batching was intended to make the process more efficient and less expensive when multiple related services are disputed. However, the law’s implementations and regulations quickly became a subject of litigation.
The proposed rule, as currently drafted, does align more closely with the letter of the law, which could reduce the risk of further successful litigation.
What will stay the same and what will change?
Not everything is changing! The original statutory requirements for batching continue to be:
- Items and services furnished by the same provider or facility.
- Payment for the items and services are made by the same group health plan or health insurance issuer.
- Items and services were furnished during the 30-day period following the date on which the first item or service included in the batched determination was furnished (or had a 30-business-day open negotiation period that ended during the same 90-calendar-day cooling off period).
- Such items and services are related to the treatment of a similar condition.
- Expanded batching criteria
- In a much-anticipated change, the proposed rule would unanimously define treatment of a similar condition. Today, each entity enforces its own definitions of treatment, which can cause confusion among the parties, especially because batching happens prior to entity selection. Going forward, under the proposed rule, treatment of a similar condition must be:
- Provided to the same patient on one or more consecutive dates of service and billed on the same claim form.
- Billed under the same service code or a comparable code under a different procedural code system.
- Anesthesiology, radiology, pathology, and lab services within certain code categories. Please see CMS-provided categories.
- 25-item cap per batch
The second proposed batching-related changes in the new rule sets a limit on the number of items in a batch. Specifically, the new rule caps the number of line items to 25 per dispute.
In response to proposed batching changes, health care providers are calling for higher limits, arguing that a cap at 25 line items will be restrictive for complex encounters. Health plans, on the other hand, seek more limits on batching scope and clearer definitions on “related services” that can be included in a batch.
For questions or further explanation of these proposed batching changes, be sure to contact our Account Services team at IDRE@fhas.com.
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The information contained in this content piece is for general informational purposes only. While we strive to ensure the accuracy and completeness of the information presented, we make no representations or warranties of any kind, express or implied, about the accuracy, reliability, suitability, or availability with respect to the content or the information, products, services, or related graphics contained in the content piece for any purpose. Any reliance you place on such information is therefore strictly at your own risk. The content of this page is subject to change without notice. The information provided in this document does not constitute legal or other professional advice, and is non-binding upon FHAS and any federal government agencies.
