Since the inception of IDR under the No Surprises Act, only a fraction of the disputes have been initiated by health plans. Furthermore, of the 75,000-plus payment determinations made via IDR in the fourth quarter of 2023, a health plan or issuer was the prevailing party in just 15 percent of the cases.
| 2023 Q4 IDR Disputes | |
| Total Federal IDR Disputes Initiated | 317,873 |
| Total Payment Determinations Made | 107,865 |
| Number of Payment Determinations where the Health Plan or Issuer is the Prevailing Party | 11,543 |
Based on this data, it’s not surprising that insurance carriers believe that participating in Independent Dispute Resolution does not benefit them. However, the reality is not nearly that simple. When completed correctly, IDR is a fair process that gives both payers and providers an equal opportunity to make their case.
As the leading IDR entity with over 225,000 IDR disputes closed (as of July 2024), FHAS emphasizes a seamless IDR process that both parties can trust. Changes to the IDR batching policies implemented in December 2023 have made IDR more accessible for both specialized healthcare providers and health plans, increasing cost-effectiveness and ease of use.
These new filing options and faster processing times encourage businesses seeking claims resolution to utilize IDR more often. As payers become familiar with the process, we expect to see an increase in their initiations and success rate. Health plans can expedite this shift by better understanding the challenge of default determinations, learning how to address objections to IDR and developing stronger offers for arbitrators to review.
We know that one of the biggest struggles payers are experiencing is determinations being forced upon them when they were not correctly routed to their email. When this is discovered, FHAS will rescind any default determinations that may have resulted, per the guidance received from CMS.
Insurers can trust that a provider cannot enforce a determination that resulted from a payor not being notified. If the error was made during open negotiation, it will be closed with no resubmission, so the mandatory open negotiation period can occur. If the inaccuracy is limited to the notice of initiation, it will be eligible for resubmission.
When submitting a dispute for IDR, it’s not uncommon for the non-initiating party to challenge the claim as ineligible under the No Surprises Act. An IDR entity will overrule the objection if it is unmerited, but the initiating party must provide the proper documentation to address these objections.
Based on our experience in IDR, objections to eligibility are typically based on one of several possible reasons. Initiating parties can keep an IDR claim on track to closure by anticipating these objections and being prepared to address them with the appropriate documentation.
| Reason for Objection | How to Address |
| Lack of a Mandatory Cooling Off Period | Any previous determination by an IDR entity must be provided if not rendered by FHAS. This information allows us to determine if a Cooling Off Period is applicable. If the dispute is a resubmission, no Cooling Off Period is required. |
| Disputes are Incorrectly Bundled | Provide the Explanation of Benefits showing the proper bundle. |
| Disputes are Incorrectly Batched | Provide proof health plan type, as well as differing group numbers. |
| Non-Compliance with State Law | Provide the Explanation of Benefits with state-specific remark codes and proof of health plan type. |
| Item is not covered by the No Surprises Act | Provide the Explanation of Benefits and a Certificate of Coverage. |
| Open Negotiation Notice / Notice of Initiation Not Received | Provide proof of delivery documents. |
| Open Negotiation Notice / Notice of Initiation Untimely | Provide proof of delivery documents. |
Previously, many objections were made based on submissions exceeding the four-business day initiation deadline following Open Negotiation. CMS now filters untimely IDR initiations by giving the initiating party an error message when submitting a dispute late, which does not allow them to proceed.
Once all objections are resolved, a claim can proceed to the offer stage. Since the arbitrator is required to select one of the two competing offers, submitting a strong and concise offer is vital.
We recommend each party provide succinct briefs that contain case-specific information organized by statutory factors. Remember to minimize the use of broad information that does not address the case's unique facts. Be sure to include pertinent information concerning QPA and its calculation in the relevant market area, along with any relevant documentation to support offers higher than the QPA.
With a streamlined path to closure and well-built offers, insurance carriers can be confident that IDR is a viable alternative to expensive litigation that contributes to more efficient billing processes.
To learn more about the advantages of IDR for your organization, contact FHAS today. Our experienced team is ready to answer your questions and provide better clarity when participating in the No Surprises Act.