IDR Common Objections Series - Part 4

Review of the most frequent objections seen by IDREs

Welcome to the fourth installment of our common objection series. If you have missed any part in the series, you can review them here: 

• Part 1: No/Untimely IDR Initiation and No/Untimely Open Negotiation
• Part 2: No Claim Information and Unidentifiable Claim
  
• Part 3: NSA not Applicable

This article will cover Incorrect bundling & batching and some of the frequent mistakes made by providers when submitting disputes for resolution.

Incorrect Bundling

Common errors include:

• Disputes involving bundled services are submitted and recorded under a single emergency episode of care, despite the use of multiple service codes.
• Disputes for a single line-item are submitted, yet they include the total cost of all items and services provided during the episode of care.

How to Avoid these Errors

The IDR entity will need to confirm during the eligibility review whether a dispute satisfies the regulatory definition of a bundle and whether either party billed or paid for the items and services using a single service code. To do this, the entity will review supporting documentation submitted by both parties to verify that either:   

• the claim form demonstrates that all items and services were billed using a single service code, or 

• a payer-generated document (e.g., remittance, explanation of payment, explanation of benefits, etc.) demonstrates that all items and services were reimbursed using a single service code. For example, a payer’s remittance lists multiple line items but provides payment on only a single line item listed in the remittance. 

If the items and services were not billed or paid for using a single service code, then the bundle is not valid, and the initiating party would need to resubmit the dispute within four business days.  

Also note, the entity will evaluate which offer best represents only the value of the submitted service code, as opposed to the total value of all the items and services furnished during the same episode of care. 

Incorrect Batching

Common errors include: 

• An initiating party does not follow the entity’s batching guidance
• Items and services were not furnished by the same provider or facility (for the health plan type)
• Payment for the items and services was not made by the same group health plan (for the health plan type)
• Items and services were furnished outside of the 30 days following the date on which the first item or service included in the batch was furnished, and a cooling-off period did not occur. 
  

How to Avoid these Errors

Unlike most IDR dispute requirements, the Departments offer suggested guidance for batching as it relates to “treatment of a similar condition”—allowing each entity to define its own batching guidelines. Therefore, it is important to contact the entity and ask for these guidelines before submitting batched disputes. 

For FHAS, we have published our guidelines based on the Departments’ guidance. You can find CMS’s guidance and our guidelines here: Batching Guidelines.

Notably, the Departments included in their proposed guidelines that entities limit batched determinations to 25 qualified items and services (or “line items”) in a single dispute to ensure timely determinations. However, FHAS has no limit to the items/services included in a batched dispute.

Pro tips to minimize batching resubmissions: 

• The initiating party should contact the entity to get clarity on their batching guidelines, including line-item limits
• Include an EOB (Explanation of Benefits) in your supporting documentation to help the entity understand your intended batching method.  

Conclusion

It’s easy to see how simple mistakes can lead to dispute cancellation and delay. Taking the time to review a dispute before formally submitting it can help avoid unwanted delays and determinations.