Delaware IDR Arbitration For Medical Revenue Recovery

Overview of the Delaware SBL

The Delaware Surprise Billing Law (SBL) came into effect in 2016, introducing provisions to protect patients from unexpected out-of-network (OON) emergency service costs. Key aspects of the law include:

• A requirement for carriers to pay for OON emergency room (ER) services at "the highest allowable charge."
• The establishment of an arbitration process to resolve payment disputes, with a 60-day timeline to initiate arbitration proceedings.

These provisions are codified under Delaware Code Title 18, Chapter 35.

Bifurcation and Applicable State Laws

The Centers for Medicare & Medicaid Services (CMS) clarified that Delaware does not have an All-Payer Model Agreement in place to determine out-of-network rates. Instead, the determination relies on specified state laws. Based on a survey response, communications with key Delaware agencies, and CMS's independent research, the following statutes apply:

• 18 Del. Code §§ 3349 and 3565

These laws govern the calculation of out-of-network rates for covered emergency services provided by non-network providers to individuals with specific health insurance coverage in Delaware.

This position was reaffirmed in a letter from CMS to the Governor of Delaware, dated January 31, 2022.