Review of the most frequent objections seen by IDREs
This is the third installment of our series covering common errors, omissions, and objections seen by Independent Dispute Resolution Entities (IDRE) in the IDR process.
If you haven’t had the chance to read the first two articles in the series, you can find them here:
Part 1: No/Untimely IDR initiation and No/Untimely open negotiation
Part 2: No claim information and Unidentifiable claim
This article outlines the issue of No Surprises Act (NSA) Not Applicable.
This is included in our list of common errors because parties are still submitting claims that are not applicable under the NSA and experiencing closures and additional fees as a result.
What is Not Applicable?
The Federal IDR process does not apply in cases where a state law or an All-Payer Model Agreement establishes a method for determining the final out-of-network (OON) payment amount. This includes services charged to:
- Medicare
- Medicaid
- Medicare Advantage
- TRICARE
- Indian Health Services
- Veterans Affairs Health Services
- Short-term Limited Duration
- Excepted Benefits (e.g., stand-alone dental or vision)
- Retiree-only
- Workers Compensation
- Health Care Sharing Ministry
What is Applicable?
Rules were established in the Federal IDR process that may be used following the end of an unsuccessful open negotiation period to determine the OON rate for services.
The following parties may use this process:
- OON providers and facilities
- OON air ambulance services
- Group health plans
- Health insurance issuers in the group and individual market
- FEHB carriers
More specifically, in situations where an All-Payer Model Agreement or specified state law does not apply, the Federal IDR Process may be used to determine the OON rate for “qualified IDR items or services,” which includes:
- Emergency services
- Certain non-emergency items/services
- Air ambulance services
These rules generally apply to group health plans and health insurance issuers offering group or individual health insurance coverage (including grandfathered health plans). It also includes FEHB carriers offering health benefit plans under 5 U.S.C. 8902, with plan/policy/contract years beginning on or after January 1, 2022.
Conclusion
Knowing the difference between what is applicable and what is not can help you make quick decisions on whether or not to initiate a dispute and help avoid unnecessary paperwork and fees.
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