Two companies that settle out-of-network medical-bill disputes can no longer accept new cases after federal agencies denied their recertification. Appeals remain available. If you are a patient, doctor or health plan with a surprise-bill dispute, here is what that means.
The agencies denied their recertification applications under the No Surprises Act; appeals remain available.
The November 4 CMS notice names Island Peer Review Organization, known as IPRO, and Network Medical Review Company. The departments of Health and Human Services, Labor and the Treasury said both failed to meet minimum performance standards.
Existing cases await guidance; appeals remain available
Providers and health plans with open disputes at either entity should expect further federal guidance on next steps. The two entities can no longer accept new cases.
Both have 30 business days from the date of their written denial notice to request an appeal. The agencies will not issue a final denial of recertification until that period has expired and any appeals received have been considered.
The agencies are also reviewing recertification petitions involving eight other entities. The decision does not change any other arbitrator’s certification status.
What the change means for medical bills
The federal independent dispute resolution process settles payment disagreements between health plans and providers, facilities or air ambulance services when negotiations fail. It operates behind the patient protections in the No Surprises Act.
For people with most private health insurance, those protections cover unexpected out-of-network bills for emergency care and certain care at in-network hospitals, hospital outpatient departments and ambulatory surgical centers, as well as air ambulance services. Ground ambulance bills generally are not covered by the federal law.
Patients who believe a provider has violated the rules can call the No Surprises Help Desk at 1-800-985-3059.
The Coalition Against Surprise Medical Billing welcomed the decision November 5 and urged a pause in pending recertifications, arguing for greater accountability and oversight.
Related change: a new dispute-management portal
CMS also says organizations with IDR Gateway accounts can begin submitting dispute web forms and accessing dashboards and reports November 13. Most forms will no longer be available outside the Gateway after January 15, 2027.
JBizNews Desk | Washington
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