CMS Updates No Surprises Act to Simplify Medical Billing Disputes

WASHINGTON—The Centers for Medicare & Medicaid Services (CMS) has made changes to the No Surprises Act (NSA), a federal law that protects patients from receiving unexpected “surprise” medical bills by preventing out-of-network providers from billing patients for the difference between their total charges and what the patient’s insurance pays. 

“Americans should never be blindsided by unexpected medical bills,” said Department of Health & Human Services Secretary Robert F. Kennedy Jr. in the announcement. “This rule cuts through bureaucratic delays, strengthens transparency between payers and providers, while continuing to protect patients from unnecessary financial stress.”

CMS said it made the changes in an effort to streamline the payment dispute process for providers, including durable medical equipment (DME) suppliers, working with group health plans and health insurance providers. In partnership with the Department of Labor, the Department of the Treasury, and the Office of Personnel Management, CMS said the new rule “directly addresses bottlenecks by helping to reduce the number of ineligible disputes entering the system at a lower cost to payers and providers.”

The key aspect of the new rule reduces the administrative fee per party and per dispute from $115 to $15. CMS said the rule also allows more flexibility for claims to be resolved in a single batched dispute, which the organization hopes will reduce costs and place limits on the number of claims per batched dispute.

In a recently published announcement, the organization said the federal Independent Dispute Resolution (IDR) system has received more than 5 million disputes since its introduction in April 2022.

According to CMS, the IDR Gateway will eventually be used to require payers to register. It hopes that this will ‘make it easier’ for providers to identify the correct party, reduce errors and avoid unnecessary disputes. Other additional features, including in-portal negotiation, will roll out over time to improve accountability and reduce unnecessary filings.”

“Today, the Trump Administration is taking an important step to strengthen the federal Independent Dispute Resolution process and ensure it works as Congress intended under the No Surprises Act,” said Acting Secretary of Labor Keith Sonderling. “By improving transparency, streamlining dispute review and ensuring consistent communication standards, we are helping all parties obtain timely, fair payment determinations while reducing administrative burdens. Most importantly, these improvements support the continued protection of patients from surprise medical bills and reinforce our commitment to a simpler, more reliable healthcare system.”

The American Hospital Association (AHA) voiced its support for the changes to the new rule.

“AHA strongly supports Congress’s approach to protecting patients from unexpected medical bills through the passage of the NSA,” it said. “Patients are protected against unexpected medical bills for certain types of healthcare services when provided by out-of-network providers, and Congress allowed for providers and payers to work collaboratively to determine reimbursement; the IDR process is included should negotiations between the two parties break down.

“While we support the underlying goals and structure of the NSA, we have raised concerns over implementation of the statute, particularly regarding the IDR process,” AHA continued. “A high-functioning and unbiased IDR process is crucial for fully realizing the NSA’s patient protections, as inappropriate reimbursement can impact providers’ ability to offer services or offer them in the timeframe or of the quality that patients deserve. We are pleased that the proposals in this rule address many of the areas of concern to hospitals and health systems and, if finalized, should significantly improve the process.”

To access the fact sheet for the new rule, click here.