IDR Common Objections Series - Part I

Review of the most frequent objections seen by IDREs  

This is the first in a series of articles that will review the most common objections, errors, and issues seen in the Independent Dispute Resolution process. 

The Centers for Medicare & Medicaid Services (CMS) require all parties follow strict guidelines, including certified Independent Dispute Resolution Entities. It is in both parties’ best interest to avoid mistakes and omissions. Errors can lead to disputes being deemed ineligible or rulings favoring the opposing party.  
 
This article outlines two common objections—no/untimely IDR initiation and no/untimely open negotiation—and provides a correct process to address them: 

No/Untimely IDR Initiation

• The initiating party fails to submit the dispute via the CMS portal.  
• The initiating party sends the initiation notice to an incorrect email address (e.g., it is misspelled, outdated, or not the address specified by the non-initiating party). 
• The notice is not sent to the non-initiating party on the same day as CMS submission.

No/Untimely Open Negotiation 

• The initiating party sends the open negotiation notice to an incorrect email address (e.g., it is misspelled, outdated, or not the address specified by the non-initiating party). 
• The notice is not sent within 30 business days of receiving the initial payment or denial notice. 

How to Address Objections 

To ensure compliance with CMS guidelines and avoid potential objections, follow these steps within the specified timelines.

Verify Contact Information 

• Obtain and confirm the correct email and phone number for the non-initiating party from the initial payment, denial notice, or otherwise provided by the non-initiating party.  
• If unsure, contact the non-initiating party to verify details before submission. 

Initiate Open Negotiation 

• Send the CMS Open Negotiation Notice to the non-initiating party electronically (or in paper form upon request) within 30 business days of receiving the initial payment or denial notice. 
• Confirm receipt with the non-initiating party.  
• Note: The initiating party should submit proof of delivery that clearly shows the email address it was delivered to, including a date and time stamp. It should be uploaded via the CMS portal upon initiation. If the information is not provided, then the entity will have to determine eligibility with the information given.

Conduct Open Negotiation  

• Engage in good-faith negotiations for 30 business days to resolve the out-of-network rate dispute.
• Note: If the provider issued prior notice and the patient waived surprise billing protections, the Federal IDR process cannot be initiated. 

Initiate IDR Process  

• If no agreement is reached within 30 days, submit the Notice of IDR Initiation via the CMS portal within four business days after the open negotiation period.  
• On the same day, send the initiation notice to the non-initiating party using the verified contact information.  
• Note: Proof of delivery, including email address, date and time may be required by the entity. If the information is not provided, then the entity will have to determine eligibility with the information it was given. 

Request Extensions if Needed  

• If technical issues or confusion cause delays, it may be possible to apply for an extension through CMS before deadlines lapse.  This article explains extensions in more detail. 
• Provide proof of delivery (e.g., email confirmation) if requested by the IDR entity.  
  
  A full explanation of these steps can be found in the CMS guidelines. 

Conclusion 

Following CMS guidelines to the letter is an important part of successful dispute resolution. Simple mistakes can have unwanted consequences, so it is in both parties’ best interest to pay careful attention to the details required in the dispute process.