Illinois IDR Arbitration For Medical Revenue Recovery

The Illinois Surprise Billing Law (SBL)

The Illinois SBL, effective January 1, 2019, outlines the following provisions:

1. Negotiation and Arbitration Timeline:
   • Providers and insurers have 30 days from the date of the Explanation of Benefits (EOB) to negotiate payment.
   • If negotiations fail, arbitration can be filed, though no specific time limit is set for filing arbitration after the 30-day negotiation period concludes.
2. Scope of Services Covered:
   • The law applies to both emergency services and inadvertent out-of-network (OON) services.
3. Arbitration Process:
   • Arbitration disputes are resolved through the American Arbitration Association (AAA).
4. Reimbursement Standards:
   • No explicit reimbursement standard is defined, though a “reasonableness” standard is presumed.
   • The Qualified Payment Amount (QPA) cannot be given preferential treatment over other considerations.

These provisions are codified under the Illinois Insurance Code, 215 ILCS 5/356z.22.

Federal & State Coordination on Out-of-Network Rates

1. All-Payer Model Agreement:
   • Illinois does not have an applicable agreement to establish OON rates.
2. Specified State Laws:
   • 215 ILCS 5/356z.3a governs OON rate determinations for the following services:
     • Pathology, Anesthesiology, Neonatology, Radiology, or Emergency Department Services provided by nonparticipating providers at participating hospitals and ambulatory surgical treatment centers.
3. Federal Independent Dispute Resolution:
   • For cases not covered by 215 ILCS 5/356z.3a, 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 applies.
   • This process governs:
     • Nonparticipating providers and emergency facilities.
     • Nonparticipating air ambulance services.
   • The federal process's outcomes will be enforced by CMS for these cases in Illinois.

This framework is detailed in a letter from CMS to the Governor of Illinois, dated April 7, 2021.