Connecticut IDR Arbitration For Medical Revenue Recovery

The Connecticut SBL Overview

The Connecticut SBL Overview

The Connecticut Surprise Billing Law (SBL) became effective on July 1, 2016. Key provisions include:

1. Reimbursement for Out-of-Network (OON) Emergency Room Services: These services are reimbursed at Usual, Customary, and Reasonable (UCR) rates.
2. Reimbursement for Inadvertent OON Services: These services are reimbursed at In-Network (INN) rates.

These provisions are outlined in Connecticut General Statutes (CGS) Section 38a-477aa.

Federal & State Coordination on Dispute Resolution

Regarding bifurcation and out-of-network reimbursement, the Centers for Medicare & Medicaid Services (CMS) have clarified that:

1. All-Payer Model Agreement: Connecticut does not have an applicable agreement that sets out-of-network rates.
2. Applicability of CGS Sec. 38a-477aa:
   • This state law determines OON rates for:
     • Certain healthcare services provided by OON providers at an INN facility.
     • OON clinical laboratory services referred by an INN provider.
     • Emergency services provided to individuals insured by Connecticut carriers.
3. Federal Independent Dispute Resolution (IDR) Process:
   • For items and services not covered by CGS Sec. 38a-477aa, the federal IDR process under Section 2799A-1(c) of the Public Health Service (PHS) Act and 45 CFR 149.510 applies.
   • For air ambulance services, the federal IDR process under Section 2799A-2(b) of the PHS Act and 45 CFR 149.520 applies.

Enforcement

• State Enforcement: Connecticut enforces the outcomes of the federal IDR process for applicable cases under Section 2799A-1(c) of the PHS Act.
• Federal Enforcement: CMS oversees enforcement of federal IDR outcomes for air ambulance services under Section 2799A-2(b) of the PHS Act.

This information was documented in a letter from CMS to the Governor of Connecticut, dated December 21, 2021.