CMS offers guidance on medical billing disputes in wake of Texas court ruling


Boram Kim


Following a recent US District Court ruling on the federal government’s arbitration process for disputed medical billing—making the protocol for issuing decisions on disputed claims unclear—CMS posted some clarifying guidance on processing payment determinations to providers on Friday. 


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The Texas Medical Association (TMA) filed a lawsuit against the departments of Health and Human Services, Labor, and the Treasury in October—after months of litigation about the federal government’s interim final rules on independent dispute resolution (IDR)—alleging that final rules in the government’s IDR process unfairly favor insurers.

Federal Judge Kernodle of the Eastern District of Texas agreed, stating rules around determining the qualifying payment amount (QPA) violated the No Surprises Act. He ruled in favor of TMA earlier this month, nullifying the final rules and making the process for negotiating disputed claims uncertain.

In the new guidance, CMS instructed stakeholders involved in the IDR process to resume processing payment determinations for disputed medical claims presented before Oct. 25th of last year, contending that cases before that date are not affected by the ruling and should be determined based on the federal guidelines approved in October 2021.

For cases after Oct. 25th, the federal government is required to update its regulations around IDR in compliance with Judge Kernodle’s ruling.

“Certified IDR entities will continue to hold issuance of payment determinations that involve items or services furnished on or after Oct. 25th, 2022, until the departments issue further guidance,” read the CMS notice. “The departments are working diligently to complete necessary guidance and system updates in order to allow certified IDR entities to resume processing payment determinations for these disputes.”

According to federal regulators, 74% of the more than 90,000 IDR requests submitted by providers through the federal arbitration portal between April and September of 2022 remain open cases and would be included under the resumption of reviews. 

Last February, Kernodle sided with TMA in another case related to the QPA, which caused federal regulators to remove the “presumption” language from the final rules.