The overwhelming response to the 2022 passing of the No Surprises Act legislation has led to a growing backlog of federal Independent Dispute Resolution (IDR) claims. For eligible disputes, the Centers for Medicare & Medicaid Services (CMS) has established specific deadlines to govern the completion of each step.
However, as the process has evolved, some aspects of the timeline have changed. This, coupled with uncertainty among providers, payors and some IDR entities, has led to a lot of frustration for those involved.
Understanding the current IDR timeline is key to navigating this confusion and completing a federal IDR claim successfully. It’s particularly important for the participants to meet the requirements that precede a claim, and abide by the deadlines that occur in initial days of the initiation of a dispute. Failure to do so could result in the inability to pursue IDR or one party’s offer not considered at all.
Calendar days vs. business days
One of the factors that causes problems for the parties involved in an IDR claim is a reliance on calendar days for some windows of time and business days for others. As you continue to explore the IDR timeline, be sure to note which approach is relevant for each deadline.
Either party can initiate the Federal IDR Process by submitting a Notice of IDR Initiation to the other party and to the Departments, but this request can only happen after the completion of certain criteria.
The parties are required to undertake a mandatory open negotiation period lasting a full 30 business days. Each party then has 4 business days after the close of the open negotiation period to initiate the IDR process. The initiating party must include their preferred IDR entity with the Notice of IDR initiation.
The non-initiating party can accept the initiating party’s preferred certified IDR entity or object and propose another certified IDR entity. A lack of response from the non-initiating party within 3 business days will be deemed to be acceptance of the initiating party’s preferred IDR entity.
If the parties cannot agree on a certified IDR entity, the Departments will randomly select a certified IDR entity on the parties’ behalf. When random selection is necessary, the Departments will do so no later than 6 business days after IDR initiation.
Each certified IDR entity also has its own CMS deadlines to comply with during the process. Once contingently selected, the entity has 3 business days to confirm that it does not have a conflict of interest and determine that the Federal IDR process is applicable. Doing so will finalize their status as the IDR entity for the case.
A certified IDR entity then has 30 business days from the date of this finalization to determine the payment amount and notify the parties and the Departments of its decision. The IDR entity must select one of the two submitted offers for its final determination. Its arbitrators cannot propose a compromised resolution.
In addition, the IDR entity must refund the prevailing party’s IDR entity fee within 30 business days after the determination.
Following finalization of the IDR entity, each party is required to submit their offer and supporting documentation within 10 business days.
The offer should also be accompanied by a payment for the certified IDR entity fee and the administrative fee. These funds will be held in a trust or escrow account until final determination. If the certified IDR entity fee and administrative fee are not collected from a party, the IDR entity will not accept the non-paying party’s offer.
Once a final determination is made, any amount due from one party to the other must be paid within 30 calendar days.
For 90 calendar days following a payment decision the initiating party cannot submit a subsequent notice of IDR initiation involving the same party and the same or similar items/services as the initial IDR.
For these items or services, either party may submit the Notice of IDR Initiation within 30 business days following the end of the cooling off period, as opposed to the standard 4-business-day period following the end of the open negotiation period. The 30-business-day period begins on the day after the last day of the cooling off period.
Extending deadlines
The timing of the payments as a result of a payment determination or settlement cannot be extended. All other time periods are eligible for an extension if necessary to address delays due to extenuating circumstances. Email requests to FederalIDRQuestions@cms.hhs.gov.
As mentioned, compliance with the initiation, offer and payment deadlines is imperative to ensuring a full review of the facts of the dispute. Ignoring the timeline or missing an important date can mean that the decision defaults to the preference of the opposing party.
Familiarity with the IDR timeline and clear communication among the involved parties and certified IDR entity is one of the best ways to prevent unnecessary delays in the process and have all relevant evidence considered.
Download our visual guide to IDR deadlines.
While each IDR entity is held to the same standard as providers and payors when it comes to these timelines, the capacity to determine a claim’s eligibility for IDR and to complete the process in a timely manner varies widely among the certified entities. A more experienced IDR entity will be better equipped to assess eligibility faster and with more accuracy than other entities.
FHAS is one of only a few IDR entities consistently complying within the CMS guidelines and operating within the mandated timelines for the IDR process from start to determination.
Any party interested in a fast and fair resolution to the IDR process can propose FHAS be the certified IDR entity for the dispute. Doing so during the initiation phase allows both parties to take advantage of our reliability and commitment to an open line of communication with all participants.
Our goal at FHAS is to help both parties better understand the timeline and how they can improve their supporting materials and the reasons behind determinations. This guidance can streamline internal processes and avoid the delays or negative consequences caused by incorrect, late or incomplete documentation.
Contact us today to learn more about the federal IDR process and how our expertise and experience can help your business resolve disputes more efficiently.