Georgia IDR Arbitration For Medical Revenue Recovery

The Georgia Surprise Billing Law (SBL)

The Georgia SBL, effective January 1, 2021, includes the following key provisions:

1. Arbitration Process:
   • Disputes are resolved through arbitration, which must be initiated within a 30-day deadline.
2. Establishment of an All-Payor Claims Database (APCD):
   • The law calls for the creation of a statewide APCD to improve data transparency and support reimbursement decisions.
3. Reimbursement Standards:
   • Reimbursement for both emergency and inadvertent out-of-network (OON) services involves a review of:
     1. The verifiable median contracted amount paid by all eligible insurers.
     2. The most recent verifiable contracted amount between the provider and carrier.
     3. A higher amount, if warranted by the complexities of the case.
4. Consideration of Additional Factors:
   • Other elements such as supporting documentation and Usual, Customary, and Reasonable (UCR) data are considered during reimbursement evaluations.
5. Claim Consolidation:
   • Providers are allowed to consolidate claims for arbitration.
6. ERISA Notice Requirement:
   • Carriers must notify providers if a claim is governed by ERISA (Employee Retirement Income Security Act).

These provisions are outlined in Georgia Code Titles 33, Section 33-20E.

Federal & State Coordination on Out-of-Network Rates

1. All-Payer Model Agreement:
   • Georgia does not have an applicable agreement to determine OON rates.
2. Specified State Laws:
   • OCGA 33-20E-8 is identified as the applicable state law for determining OON rates for:
     • Nonparticipating providers.
     • Nonparticipating emergency facilities.
     • Nonparticipating providers of air ambulance services.
3. Exemption from Federal Dispute Resolution:
   • Since Georgia’s law applies to these cases, the federal independent dispute resolution process under sections 2799A-1(c) and 2799A-2(b) of the Public Health Service (PHS) Act and 45 CFR 149.510 and 149.520 will not apply in Georgia.

This information is documented in a letter from CMS to the Governor of Georgia, dated December 13, 2021.