Patient-Provider Dispute Resolution (PPDR) Process

Under the patient-provider dispute resolution (PPDR) process, the uninsured (or self-pay) individual may seek a determination from a Selected Dispute Resolution (SDR) entity for the amount the individual has to pay.
Patient-Provider Dispute Resolution (PPDR) Process

Beginning January 1, 2022, a PPDR process will be available for uninsured (or self-pay) individuals who get a bill for an item or service that is substantially in excess of the expected charges on the good faith estimate. Under the PPDR process, the uninsured (or self-pay) individual may seek a determination from a Selected Dispute Resolution (SDR) entity for the amount the individual has to pay. This process can provide the uninsured (or self-pay) individual important consumer protections from billed charges that are substantially in excess of the expected charges in the good faith estimate.

Items or services eligible for PPDR

The PPDR process can apply to any item or service furnished by a convening provider, convening facility, co-provider, or co-facility to an uninsured (or self-pay) individual where the total billed charges are substantially in excess of the total expected charges in the good faith estimate. HHS regulations establish that when the billed charges for any provider or facility are in excess of the good faith estimate for that provider or facility by $400 or more, the item or service may be eligible for payment determination by a SDR entity through the PPDR process. As each good faith estimate could potentially contain expected charges from multiple providers and facilities, the substantially in excess determination is made separately for each specific provider or facility listed on the good faith estimate.

If a co-provider or co-facility that provided an estimate of the expected charge for an item or service in the good faith estimate is replaced by a different co-provider or co-facility less than 1 business day before that item or service is scheduled to be furnished, an item or service billed by the replacement co-provider or co-facility is eligible for dispute resolution if the billed charge is $400 or more than the total expected charges included in the good faith estimate for the original co-provider or co-facility. If the replacement provider or facility provides the uninsured (or self-pay) individual with a new good faith estimate, in a timely manner, then the determination of whether an item or service billed by the replacement co-provider or co-facility is eligible for dispute resolution is based on whether the total billed charge for the replacement co-provider or co-facility is $400 or more than the total expected charges included in the good faith estimate provided by the replacement co-provider or co-facility.

Enforcement discretion in 2022 for expected charges for items and services from a co-provider or co-facility

For good faith estimates provided to uninsured (or self-pay) individuals on or after January 1, 2022 through December 31, 2022, HHS will exercise its enforcement discretion in situations where the good faith estimate does not include expected charges for items and services from a co-provider or co-facility. During the period of enforcement discretion, items or services to be provided by a co-provider or co-facility that appear on the good faith estimate that do not include an estimate of expected charges or that appear as a range of expected charges would not be eligible for the PPDR process for the item or service provided by the co-provider or co-facility. If expected charges for a co-provider and co-facility do appear on the good faith estimate, those items or services will be eligible for the PPDR process as normal. This particular application for PPDR eligibility would only apply in 2022.

FAQs

Would a provider or facility be subject to requirements for the PPDR process but not requirements for the good faith estimate?

The good faith estimate requirements work together with the PPDR requirements to establish important consumer protections for uninsured (or self-pay) individuals who receive billed charges that are substantially in excess of the good faith estimates they received prior to scheduling (or upon request of) items or services. As a result, the requirements for the PPDR process apply to all providers or facilities subject to the good faith estimate requirements.

How is PPDR eligibility determined when there are different providers or facilities listed on the same good faith estimate?

Eligibility for PPDR is determined separately for each unique provider or facility listed on the good faith estimate. For each provider or facility, the total expected charges for each item or service should be added up. This total amount is then compared with the total of all billed charges for the provider or facility, including billed charges for items and services that were furnished but not included in the good faith estimate, to determine eligibility for PPDR.

Source: HHS PPDR Providers Guidance (cms.gov)

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