If you are in the middle of a patient-provider dispute, you may be curious about the dispute resolution process in the No Surprises Act. There are distinct rules and timelines involved in the resolution process that must be adhered to by both sides of the dispute. Learn about the dispute resolution process, the integral players, the timeline, and essential rules providers must adhere to throughout the dispute resolution process.
When can a patient initiate a billing dispute with a provider?
If a patient receives an initial bill for charges that are significantly higher than the expected charges, based on the good faith estimate, the patient can initiate a billing dispute with their provider. The charge must be at least $400 above the total expected charges in the good faith estimate, and the dispute must be initiated within 120 calendar days of receiving the initial bill containing the excessive charges. However, after the initiation, there are additional steps, each with deadlines ranging from three to 30 business days.
What is a selected dispute resolution entity?
A selected dispute resolution entity is an unbiased, independent party selected through the Patient-Provider Dispute Resolution process by the U.S. Department of Health and Human Services.
The SDR reviews the initiation notice to ensure the dispute meets the PPDR process's eligibility requirements and includes the requisite information. Then the SDR carefully analyzes the consumer's dispute and investigates the provider's explanation for excess charges. The SDR decides whether the excess charges are justified and the final amount the consumer must pay.
For the SDR to determine that an excess charge is valid, the provider must show credible information that the difference between the good faith estimate and the actual charge reflects necessary medical costs and credible information that the charge was based on unforeseen circumstances.
Depending upon the SDR's decisions, the consumer must pay one of the following:
- The billed amount
- The amount quoted in the good faith estimate
- The SDR-determined amount between the billed amount and the good faith estimate
Currently, the SDR entity has a small $25 administrative charge that the consumer must pay to initiate the PPDR process.
Patient-provider dispute resolution process and timeline
The PPDR process has distinct steps with a set timeline that must be adhered to by the consumer, the SDR, and the provider. The Department of Health and Human Services outlines the PPDR process and timeline.
1. Notice of initiation
Within 120 calendar days
The consumer submits the initiation notice and other relevant information to the HHS within the timeline. The HHS will then select and notify the SDR entity. At this point, the consumer will pay the $25 administrative fee to the chosen SDR entity.
2. Conflict of interest identification for SDR entity
Within three business days
The chosen SDR will be examined for potential conflicts of interest. If a conflict of interest is discovered, HHS will select a different SDR. If there are no other SDR entities available, the original SDR will initiate an entity-level conflict of interest mitigation plan, which may include identifying a subcontractor without a conflict of interest. The SDR entity must submit this information to HHS within three business days. At this point, HHS will assign the case to the alternate SDR entity.
3. Determination of eligibility
Within 21 calendar days
Once the SDR receives the consumer's information, it will make the following determinations and notify the consumer:
- Whether the consumer is eligible for PPDR
- Whether any additional information is needed to determine eligibility
- Whether the file is complete and the consumer may proceed to the dispute resolution stage.
If the SDR requests additional information, the consumer must supply it to the SDR within 21 calendar days.
4. Initiation of PPDR
The process moves forward if the SDR entity decides the dispute is eligible and the requisite information has been supplied. The SDR entity will notify the consumer and the provider that the dispute is eligible for dispute resolution.
5. Conflict of interest identification for parties
Within three business days
The consumer and provider may claim a conflict of interest with the SDR entity. If a conflict exists, the SDR will notify HHS within three business days of the conflict notification. HHS will then select a different SDR entity.
6. Submission of information from the provider
Within 10 business days
The provider has 10 business days to submit any necessary information to the SDR entity. The required information includes:
- A copy of the disputed good faith estimate given to the consumer
- A copy of the disputed billed charges
- Any documentation proving the increased billing resulted from a medically necessary item and was based on unforeseen circumstances
HHS strongly encourages parties to submit any required information through the federal IDR portal. The SDR entity has 30 business days from receipt of this information to decide the amount the consumer will pay.
Copy of the Good Faith Estimate
This is a copy of the estimate provided to the consumer for the services or items under dispute. Acceptable copies include photocopies and electronic images, but the document must be legible.
Copy of the billed charges under dispute
This is a copy of the billed charges the consumer is disputing. It should include the services or items the consumer disputes. Acceptable copies include legible electronic images and photocopies.
Documentation supporting the difference between expected and billed charges
This is documentation supplied by the healthcare provider to demonstrate that any difference in charges between the good faith estimate and the billed charges was justified. This documentation should prove the costs of a medically necessary charge based on unforeseeable circumstances at the time of the good faith estimate.
7. Negotiation between patient and provider
Within three business days
The parties can negotiate an acceptable payment amount after the PPDR process's initiation but before a determination is announced. If the negotiation is successful, the provider must notify the SDR entity via the federal IDR portal, in paper form, or electronically within three business days of the agreement.
The settlement notification must include at least the following:
- Settlement date
- Settlement amount
- Documentation demonstrating the parties' agreement to the settlement
- A document showing the provider reduced the consumer's settlement amount to cover at least half the SDR administrative fee
8. Determination of payment by SDR entity
Within 30 business days
The SDR entity must make a final determination regarding the amount to be paid by the consumer. This determination should consider the requirements for the PPDR payment determination process, and the SDR entity must decide within 30 business days of receiving the provider's requisite information. The SDR entity should inform the parties ASAP after the determination.
This determination is binding upon the involved parties so long as there is no fraud or misrepresentation of facts.
Exceptions to the binding determination include:
- The provider may choose to supply financial assistance.
- The provider may agree to a lower payment amount.
- The consumer may agree to pay the billed charges in full.
- The consumer and provider may agree to a different payment amount.
How does the SDR entity determine payment?
The SDR entity reviews the billed charges and all documentation submitted by the parties. The SDR entity bases its determination on the following:
- Whether the provider included the disputed charges in the good faith estimate
- Whether the provider supplied credible information to demonstrate that the increased billing reflects the costs of a medically necessary charge
- Whether the provider supplied credible information to demonstrate that the increased billing is based on unforeseeable circumstances at the time the provider quoted the good faith estimate
The SDR entity will consider each disputed item separately in relation to the above points and determine how much the consumer must pay.
Example of payment determination
Example 1: The case is ineligible if the disputed bill is equal to or less than the charge in the good faith estimate.
- Bill charged is $500
- Good faith estimate quotes $1,000
- The consumer must pay the billed charge of $500 as the case is ineligible
Example 2: The disputed item was included on the good faith estimate but was charged substantially in excess. The provider failed to provide a credible reason for the excess charge. The SDR entity determines the amount to be paid by the consumer to be equal to the good faith estimate.
- Bill charged is $900
- Good faith estimate quotes $400
- The consumer will pay $400
Example 3: If the bill charged is significantly higher than the good faith estimate, but the provider explains the difference via a credible reason, the SDR entity determines the amount to be paid by the consumer. This amount may be the lesser of the bill charged or the median payment plan of a similar service by the same provider in the same geographic area.
- Bill charged is $850
- Good faith estimate quotes $450
- The consumer will pay the lower of $850 or the median described above, or if lower than the good faith estimate, $450
Extensions and extenuating circumstances
You can extend most of the time limits in the PPDR process when extenuating circumstances arise. These extensions are issued on a case-by-case basis and generally extended to matters outside the parties' control, like a natural disaster. Parties may request extensions by submitting a Request for Extension due to Extenuating Circumstances form through the online Federal IDR portal, electronically, or by paper mail.
Provider rules during PPDR
When the PPDR process has begun, certain rules apply to the provider. The rules govern the collection, late fees, and retribution related to the disputed charges.
Collection and threats of collection are prohibited
While the PPDR process is pending, the provider is not allowed to move the bill into collections or threaten the consumer with such action. The PPDR process prohibits these actions while the process is ongoing.
Existing collection must be paused
The provider may have already moved the bill into collections. In this case, once the PPDR process begins, the provider must pause any existing collection activities on the bill until the process concludes.
Late fees on disputed unpaid charges are prohibited
Providers must suspend any late fees if they have been accruing or will begin to accrue during the PPDR process. No late fees on unpaid bills are allowed to accrue until after the PPDR process has ended.
Retribution or threats of retribution against individuals are prohibited
The provider must not stand in the way if a consumer uses the PPDR process to dispute a charge. The PPDR process prohibits the provider from seeking or threatening disciplinary action against the consumer for employing the PPDR process to resolve a disputed charge.
Can providers settle during PPDR?
HHS recognizes that the consumer and provider may settle the dispute by coming to an agreed payment amount. Providers are allowed to settle the dispute with the consumer during the PPDR process. A settlement during the PPDR process is allowed after the PPDR process initiation and before the SDR entity makes a final determination.
The settlement may include one of the following options:
- The parties agree to settle the disputed charges through an offer of financial assistance
- The parties agree to settle the disputed charges through the payment of a lower amount
- The consumer agrees to pay the disputed charges in full
If the parties arrive at a settlement agreement, they should notify the SDR entity as quickly as possible, but definitely within three business days of the agreement. The preferred notification method is via the federal IDR portal, but electronic or paper notifications are also acceptable.
Stick to all PPDR timelines for the best results
When a disputed charge enters the PPDR process, there are multiple ways the process may conclude. The SDR entity may decide the consumer should pay the full charge, the good faith estimate, something in the middle, or the parties may settle on another figure or payment plan. Regardless of the outcome, it is crucial that you follow the rules and adhere to the PPDR No Surprises Act timeline for the most favorable results.