Where Things Stand and What’s Ahead
Nearly five years after the No Surprises Act (NSA) took effect to protect patients from unexpected medical bills, efforts continue to streamline billing disputes between healthcare providers and insurers. Here, we explain what the Federal IDR Operations Rule means for payers and providers, where it stands, and how it aims to improve the Independent Dispute Resolution (IDR) process.
The IDR Operations Rule
In November 2023, the Departments of Health and Human Services, Labor, and Treasury proposed the Federal IDR Operations Rule (sometimes referred to as the Proposed Rule) to fine-tune the IDR process.
The rule introduces several key changes designed to enhance efficiency and clarity in the IDR process, including:
- Clearer billing communication: Insurers must use standard codes (CARCs and RARCs) on payment notices to explain why a claim was adjusted or denied, reducing confusion and preventing unnecessary disputes.
- Enhanced disclosures: When denying or partially paying a claim, insurers must share more details, helping providers decide whether to challenge the decision.
- Improved open negotiations: New standard forms and clearer timelines for starting negotiations make the process more efficient and consistent.
- Better IDR initiation & eligibility clarity: Rules for starting IDR disputes, like checking for conflicts of interest or eligibility, are clarified to reduce delays and ensure only valid cases move forward.
- Batching and bundling clarity: Clear guidelines defining bundled payment arrangements and improper batching criteria
- Mandatory portal registration: Insurers must register in the federal IDR portal, improving tracking and communication during disputes.
Where Things Stand Now
As of today, the IDR Operations Rule proposed in November 2023 is still awaiting finalization. Previously, the Tri-Departments received many comments on the proposed rule, which will be reviewed to shape the final version of the rule. The Rule, if finalized, will likely roll out in 2026, making the IDR process more transparent and efficient.
Currently, the Departments continue to make changes to the IDR portal in 2025, which include updates to the IDR initiation web form, such as adding a Service Code Modifier(s) field.
For now, payers and providers should:
- Review their IDR compliance processes to prepare for stricter enforcement.
- Train teams on potential new requirements, like standardized codes or portal registration.
- Stay informed on updates to the Operations Rule.
The regulatory landscape is still evolving, but one thing is clear: improvements continue to be made through CCIIO’s great efforts. FHAS continues to serve as a trusted partner, helping parties resolve disputes efficiently and uphold the highest standards of quality, fairness, and compliance.
For more information about how FHAS can support your organization, contact our Accounts Team at IDR@fhas.com, call 570-779-5122, or reach out directly to your FHAS account manager.
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