Introducing the Patient-Provider Dispute Resolution Process: Guidance Available

The patient-provider dispute resolution (PPDR) process is meant to protect uninsured (or self-pay) individuals from unexpectedly high medical bills. Effective January 1, 2022, providers, facilities, and providers of air ambulance services will need to give an uninsured (or self-pay) individual, or their authorized representative, a good faith estimate of expected charges after an item or service is scheduled, or upon request. The good faith estimate will include a list of items and services expected to be provided as part of the primary care, and items and services expected to be provided in conjunction with the primary care, for that period of care.

If an uninsured (or self-pay) individual receives a bill that is at least $400 more than the expected charges on the good faith estimate, they can choose to initiate the PPDR process, engaging a third-party entity certified by the Department of Health and Human Services (HHS) to arbitrate their dispute. This company will decide how much the uninsured (or self-pay) individual will pay to the provider or facility: the amount on the good faith estimate, the billed amount, or another amount in between the estimated amount and billed amount. To utilize this dispute process, there is a $25 administrative fee that the individual has to pay at the start of the process.

This PPDR process provides important consumer protections for the uninsured (or self-pay) individual from billed charges that are substantially in excess of the expected charges in the good faith estimate.

HHS has created PPDR guidance for different audiences. These guidance documents help providers and facilities and uninsured or self-pay individuals, and those who will help them, to better understand what information must be included in the good faith estimate, how to initiate the PPDR process, and address any questions you may have.

Guidance for Providers and Facilities: link available here

Guidance about Selected Dispute Resolution Entity: link available here

Guidance for Uninsured or (Self-Pay) Individuals: link available here

Guidance about the Administrative Fee: link available here

HHS intends to hold webinars in the future about the PPDR process. We’ll share webinar information in the coming weeks.