Maryland IDR Arbitration For Medical Revenue Recovery

The Maryland Surprise Billing Law (SBL)

Maryland's SBL, effective January 1, 2018, is unique in its use of an All-Payer Model Agreement to determine out-of-network (OON) reimbursement. Key features include:

Key Provisions

1. All-Payer Model Agreement:
   • Maryland's reimbursement framework considers Medicaid and Medicare payments as relevant inputs to determine fair and reasonable reimbursement rates for OON medical providers.
   • This agreement applies to hospital services in Maryland.
2. Applicable State Laws:
   • Title 19, Subtitle 2, Part II (Health Care Facility Rate Setting) of Maryland’s Health-General Article governs rate setting for hospital services.
   • § 19-710.1 of the Health-General Article applies to services furnished to individuals in Health Maintenance Organizations (HMOs) by noncontracted health care providers.
   • § 14-205.2 of the Maryland Insurance Article applies to covered services furnished to individuals in Exclusive Provider Organizations (EPOs) or Preferred Provider Organizations (PPOs) by nonpreferred on-call and hospital-based physicians who accept assignment of benefits.

Federal and State Coordination

1. Scope of Maryland’s All-Payer Model Agreement:
   • Determines OON reimbursement rates for hospital services in Maryland.
2. Federal Independent Dispute Resolution (IDR) Process:
   • 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 applies only for:
     • Items and services not covered by Maryland's All-Payer Model Agreement or specified state laws.
     • Cases involving nonparticipating providers, nonparticipating emergency facilities, and nonparticipating providers of air ambulance services.
3. Enforcement:
   • The Maryland Insurance Administration enforces the outcomes of the federal IDR process for cases that fall under federal jurisdiction.

This framework is confirmed in a letter from CMS to the Governor of Maryland, dated May 18, 2022, highlighting the collaborative structure between federal and state laws for determining OON reimbursement in Maryland.