The last week has been a roller-coaster ride for the Centers for Medicare & Medicaid Services (CMS) No Surprises Act (NSA) policies and processes. But roller-coaster rides for CMS’s implementation of the No Surprises Act have become the norm.
A little over a week ago, CMS put up a “closed” sign on its beleaguered Independent Dispute Resolution (IDR) process, and subsequently announced that they were pausing all IDR activities. The IDR process, just as a quick reminder, is the mediation process out-of-network providers can use if they want to argue against the reimbursement amount they received for claims that fall under the No Surprises Act.
At the time of last week’s closing, the IDR process was already extremely backlogged, with IDR entities still making their way through claims from last year.
CMS said they were pausing the process to give themselves time to digest a U.S. District Court ruling made the week before.
In essence, the Court made two significant decisions. First, the judge discarded a 600-percent increase in fees that CMS had implemented last year for the IDR. The result, for the time being, is that the fee reverts back to the original $50. Second, the judgment also threw out language in the CMS Final Rule governing the federal IDR process, which holds that batching can only be used for the same or similar items and services. The Texas Medical Association (TMA) had argued that batching should also be allowed for items and services that are provided to the same patient during the same encounter.
A day after the CMS announcement that all IDR activities had been stopped, CMS announced that it was switching gears and allowing the IDR process to start back up again for at least some NSA claims – specifically, claims for which the fee had already been paid.
In the meantime, CMS says it will continue to digest the Court’s decision, and the agency promised that it would be forthcoming with guidance on how it will proceed.
An interesting element in all this is that the judge did not throw out the administrative fee increase and CMS’s policy on batching because they were necessarily harmful to providers. Instead, the judge ruled that CMS had not followed proper notice issuance and rulemaking. In other words, CMS could decide to increase the fee again and impose the same batching definition, but this time, make sure it does so through proper rulemaking.
And that just might be an avenue CMS could take, since there is a regulation on the NSA IDR process in its final stages right now. In fact, at the time of this latest Court decision, the regulation was being reviewed by the White House.
In the meantime, last week another district court found in favor of CMS and the government with regard to the No Surprises Act: the court rejected the Association of Air Medical Services (AAMS) claim that the NSA’s methodology for calculating the qualifying payment amount (QPA) violated regulatory procedures.
Which brings us back to our roller-coaster analogy on NSA policy: wins and losses in lawsuits, one after the other; opening, closing, then opening again the IDR process; and CMS going back to the drawing board with a regulation in the works.
Hold on tight, y’all!
Every time we turn on the television, we see politics. Not just campaign commercials, but also nearly every news event – from devastating weather events
The U.S. Departments of Health and Human Services (HHS), Labor, Treasury, and the Office of Personnel Management recently released a proposed rule concerning the federal
Please log in to your account to comment on this article.
Accurately determining the principal diagnosis is critical for compliant billing, appropriate reimbursement, and valid quality reporting — yet it remains one of the most subjective and error-prone areas in inpatient coding. In this expert-led session, Cheryl Ericson, RN, MS, CCDS, CDIP, demystifies the complexities of principal diagnosis assignment, bridging the gap between coding rules and clinical reality. Learn how to strengthen your organization’s coding accuracy, reduce denials, and ensure your documentation supports true medical necessity.
Denials continue to delay reimbursement, increase administrative burden, and threaten financial stability across healthcare organizations. This essential webcast tackles the root causes—rising payer scrutiny, fragmented workflows, inconsistent documentation, and underused analytics—and offers proven, data-driven strategies to prevent and overturn denials. Attendees will gain practical tools to strengthen documentation and coding accuracy, engage clinicians effectively, and leverage predictive analytics and AI to identify risks before they impact revenue. Through real-world case examples and actionable guidance, this session empowers coding, CDI, and revenue cycle professionals to shift from reactive appeals to proactive denial prevention and revenue protection.
Sepsis remains one of the most frequently denied and contested diagnoses, creating costly revenue loss and compliance risks. In this webcast, Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, provides practical, real-world strategies to align documentation with coding guidelines, reconcile Sepsis-2 and Sepsis-3 definitions, and apply compliant queries. You’ll learn how to identify and address documentation gaps, strengthen provider engagement, and defend diagnoses against payer scrutiny—equipping you to protect reimbursement, improve SOI/ROM capture, and reduce audit vulnerability in this high-risk area.
Only ICD10monitor delivers what you need: updates on must-know changes associated with the FY26 IPPS, including new ICD-10-CM/PCS codes, CCs/MCCs, and MS-DRGs, plus insights, analysis and answers to your questions from two of the country’s most respected subject matter experts.
Get clear, practical answers to Medicare’s most confusing regulations. Join Dr. Ronald Hirsch as he breaks down real-world compliance challenges and shares guidance your team can apply right away.
Federal auditors are zeroing in on Inpatient Rehabilitation Facility (IRF) and hospital rehab unit services, with OIG and CERT audits leading to millions in penalties—often due to documentation and administrative errors, not quality of care. Join compliance expert Michael Calahan, PA, MBA, to learn the five clinical “pillars” of IRF-PPS admissions, key documentation requirements, and real-life case lessons to help protect your revenue.
During this essential RACmonitor webcast Michael Calahan, PA, MBA Certified Compliance Officer, will clarify the rules, dispel common misconceptions, and equip you with practical strategies to code, document, and bill high-risk split/shared, incident-to & critical care E/M services with confidence. Don’t let audit risks or revenue losses catch your organization off guard — learn exactly what federal auditors are looking for and how to ensure your documentation and reporting stand up to scrutiny.
Learn how to navigate the proposed elimination of the Inpatient-Only list. Gain strategies to assess admission status, avoid denials, protect compliance, and address impacts across Medicare and non-Medicare payors. Essential insights for hospitals.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
