Missouri IDR Arbitration For Medical Revenue Recovery

Missouri Surprise Billing Law (SBL)

The Missouri Surprise Billing Law (SBL), effective January 1, 2022, is codified under Missouri Revised Statutes, Section 376.690. The law addresses reimbursement for unanticipated out-of-network (OON) care and outlines procedures for dispute resolution between carriers and medical providers.

Key Provisions

1. Reimbursement Requirements:
   • Carrier Payment Timeline: Carriers must provide reasonable reimbursement within 45 days of receiving a claim.
2. Negotiation Period:
   • If a provider disputes the reimbursement amount, they have 60 days to negotiate a resolution with the carrier.
3. Arbitration Process:
   • If no resolution is reached, arbitration must be initiated within 120 days after the negotiation period ends.
   • Missouri's arbitration is not baseball-style; the arbitrator has flexibility in determining the reimbursement amount.
4. Reimbursement Determination:
   • The arbitrator can decide on an amount between 120% of Medicare and the 70th percentile of an objective usual, customary, and reasonable (UCR) value.
   • Factors considered include standard measures of UCR and other relevant information.
5. Scope of Application:
   • The law applies specifically to emergency treatment.
   • It excludes inadvertent OON treatment.
6. Consolidation of Claims:
   • Similar claims may be consolidated for arbitration to improve efficiency.

Federal and State Coordination

1. State Enforcement:
   • Section 376.690, RSMo, governs unanticipated OON care for individuals with coverage from health carriers in Missouri when provided by OON professionals at in-network facilities.
2. Federal Independent Dispute Resolution (IDR) Process:
   • Federal IDR applies in cases where:
     • Section 376.690, RSMo, does not apply, including for nonparticipating emergency facilities.
     • Air ambulance services are involved.
   • Outcomes of the Federal IDR process are enforced by CMS for applicable cases in Missouri.

These details are outlined in a CMS letter to the Governor of Missouri, dated December 23, 2021, emphasizing the integration of state and federal processes to ensure fair OON reimbursement mechanisms.