New Jersey IDR Arbitration For Medical Revenue Recovery

New Jersey Surprise Billing Law (SBL)

The New Jersey Surprise Billing Law (SBL) took effect on August 30, 2018, and is codified under N.J.S.A. 26:2SS-1 to -20. It addresses reimbursement for out-of-network (OON) services rendered in specific scenarios and establishes a process for dispute resolution between providers and insurers.

Key Provisions of the New Jersey SBL

1. Reimbursement Standard:
   • Payments for OON services must be at a “reasonable” amount based on the circumstances and available data.
2. Dispute Resolution Timeline:
   • The initiating party (provider or insurer) must:
     • Object to the payment and
     • File for arbitration within 60 calendar days of receiving the disputed payment.
3. Arbitration Evidence:
   • Data on Usual, Customary, and Reasonable (UCR) charges can be submitted during arbitration.
   • UCR data often plays a critical role in determining the prevailing position.

State and Federal Coordination

1. Specified State Laws:
   • N.J.S.A. 26:2SS-1 to -20 applies in the following scenarios:
     • Services Covered:
       • Out-of-network services rendered on an inadvertent basis (e.g., patients unknowingly receiving care from OON providers) or in emergency or urgent situations.
     • Provider Settings:
       • Services must be rendered by a health care provider licensed or certified in New Jersey.
     • Plans Covered:
       • Applies to health benefit plans issued in New Jersey.
2. Federal Independent Dispute Resolution (IDR):
   • The federal IDR process applies to cases not governed by N.J.S.A. 26:2SS-1 to -20, including:
     • Nonparticipating Providers and Facilities:
       • Claims involving providers and emergency facilities outside the scope of New Jersey’s SBL.
     • Air Ambulance Services:
       • Claims for services provided by nonparticipating air ambulance providers.
3. Enforcement:
   • New Jersey seeks voluntary compliance with federal IDR outcomes.
   • In cases where compliance is not achieved, CMS enforces the federal IDR decision.

CMS Clarifications

In a letter from CMS to the Governor of New Jersey (February 4, 2022), the following points were emphasized:

1. No All-Payer Model Agreement:
   • New Jersey does not have an All-Payer Model Agreement to establish OON rates.
2. Application of State Law:
   • N.J.S.A. 26:2SS-1 to -20 is recognized as a specified state law for determining OON rates for inadvertent and emergency/urgent OON services provided to individuals covered under health plans issued in New Jersey.
3. Federal Oversight:
   • The federal IDR process applies to cases outside the scope of New Jersey’s SBL. CMS is responsible for enforcing the outcomes of these federal dispute resolutions in New Jersey.

This framework ensures that both state and federal protections address surprise billing disputes while minimizing gaps in coverage and enforcement.