Maine IDR Arbitration For Medical Revenue Recovery

The Maine Surprise Billing Law (SBL)

The Maine SBL, effective January 1, 2018, includes the following key provisions:

1. Provider Reimbursement Requirements:
   • Providers must be reimbursed at the greater of:
     1. The in-network (INN) rate of the carrier, or
     2. The average INN rate of all carriers, as determined by the state’s All-Payor Claims Database (APCD).
2. Independent Dispute Resolution (IDR) Process:
   • An IDR arbitration process is available for resolving disputes between providers and carriers.
3. Negotiation Period:
   • Parties have a 30-day period to negotiate a resolution, starting from the payment date.
4. Arbitrator Considerations:
   • The arbitrator may consider:
     • The provider’s level of training.
     • Previously contracted rates between the provider and carrier.
     • Usual, Customary, and Reasonable (UCR) rates, as determined by the APCD.
     • Other relevant factors.

These provisions are codified under Title 24-A, Maine Insurance Code, Chapter 56-A, §4303-C.

Federal & State Coordination on Out-of-Network Rates

1. All-Payer Model Agreement:
   • Maine does not have an All-Payer Model Agreement to determine out-of-network (OON) rates.
2. Specified State Laws:
   • Title 24-A, Chapter 56-A, §4303-C is the specified state law for OON rate determinations in Maine.
   • This applies to items and services furnished by:
     • Nonparticipating providers.
     • Nonparticipating emergency facilities.
     • Nonparticipating air ambulance providers.
3. Federal Independent Dispute Resolution:
   • The federal IDR 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 does not apply to cases covered by Maine’s state law.

This framework is detailed in a letter from CMS to the Governor of Maine, dated December 22, 2021.