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Where Providers and Health Plans Go Wrong In Filing IDR Disputes

By June 27, 2024July 10th, 2024No Comments

The No Surprises Act was created to protect patients from unexpected medical bills and set up the Independent Dispute Resolution (IDR) process to sort out payment disagreements between healthcare providers, facilities, and insurance plans. 

This process is necessary for making sure the appropriate parties get paid fairly. However, the IDR process can be complicated, and there are some potential pitfalls that can lead to negative outcomes. By learning about and avoiding these common errors, stakeholders can navigate the IDR process more effectively, ensure compliance with regulations, and get the most fair financial outcomes. 

There are several ways that a party (provider, facility, or health plan) could potentially file their payment dispute incorrectly or improperly under the No Surprises Act’s Independent Dispute Resolution (IDR) process. Let’s look at some key mistakes in filing an IDR dispute, as well as how to best manage the process and avoid pitfalls.

The IDR process under the No Surprises Act has firm timeframes that must be followed for a dispute to be considered. After the 30 business day open negotiation ends, parties have a window of 4 business days, starting the day after the last day of open negotiation, in which they can initiate the IDR process.

Missing this window can have serious consequences, such as losing the opportunity to use the IDR process for that particular payment dispute. It’s imperative for providers, facilities, and health plans to be aware of and track these deadlines closely to make sure they do not miss the filing period.

One frequent issue is mistyped email addresses. Always copy and paste email addresses to avoid errors. If the Complainant’s (IP) email is wrong, they won’t receive the IDR initiation or future dispute communications unless the error is caught. 

If the Respondent’s (NIP) email is wrong, they won’t receive the Entity Selection Response Form or future dispute communications unless the mistake is identified. The IP email can be corrected without closing the dispute, but all communications must be resent. If the NIP email is corrected, the dispute must be closed and resubmitted to send the form to the correct address.

Another common issue is swapping the IP and NIP contact information. Ensure the contact information is being pasted into the correct text fields:

  • IP (Complainant Email)
  • NIP (Respondent Email)

Be aware that the CMS link will only send to the Complainant Email, not the Primary Contact email. However, FHAS invoices are sent to both.

It’s necessary to choose the right entity to manage your case when entering the IDR process. The disputing parties must jointly choose a certified Independent Dispute Resolution (IDR) entity from a list approved by federal regulators. This step ensures the process is fair and unbiased.

There are specific guidelines under the No Surprises Act preventing IDREs from affiliating with healthcare providers, insurers, or related entities, ensuring neutrality in arbitration. FHAS exemplifies this approach through rigorous compliance measures, including staff training and conflict reporting systems, to maintain impartiality and uphold the integrity of the IDR process.

Here is how to select an unbiased IDRE.

In IDR dispute resolution, accurate calculations play a fundamental role, particularly in determining the Qualifying Payment Amount (QPA) and other financial metrics. These calculations assess payment disputes.

For instance, if a healthcare provider submits incorrect figures for the QPA, such as misinterpreting billed charges or allowable amounts, it could weaken their argument during the IDR review. Similarly, insurance plans must ensure they accurately calculate the QPA based on contractual agreements and regulatory guidelines to support their stance in the dispute.

Upholding accuracy in these computations not only strengthens a party’s case but also upholds the integrity of the IDR process, promoting the most equitable resolution for all parties.

When initiating an Independent Dispute Resolution (IDR) process, it is imperative that you provide all required documentation and details. Under the No Surprises Act, arbitrators must select an offer from either the initiating or non-initiating party — without creating a unique payment amount. 

To build a strong case for your offer, parties need to present detailed documentation, including:

  1. Proof of good faith negotiation attempts
  2. Relevant plan documents
  3. Proof of payment
  4. Medical records
  5. Provider credentials
  6. Previously negotiated rates

Learn more on how to make your IDR documentation stronger.

Missing any key pieces of information can cause significant delays or rejections, necessitating a restart of the process and potentially leading to longer resolution times and negative financial impacts.

Additionally, some states may have specific documentation requirements for IDRs involving their health plans or providers.

If you have questions about needed documentation, FHAS is an industry leader in healthcare claims adjudication, with over 100,000 IDR payment determinations issued.

The IDR process helps determine out-of-network (OON) payment amounts for emergency services, non-emergency services by OON providers at in-network facilities, and air ambulance services. However, it does not apply to items payable by Medicare, Medicaid, the Children’s Health Insurance Program, or TRICARE, or when a state law (SSL) or All-Payer Model Agreement (APMA) exists to determine OON payments. In bifurcated states, certain OON services may fall under either the Federal IDR process or an SSL/APMA, requiring certified IDR entities to determine eligibility for the Federal process.

Review this chart to see the 28 states and the District of Columbia that follow the Federal IDR process for all qualified items and services. It also highlights the eight states where self-funded plans can opt for state-specific processes. This tool provides guidance but is not a substitute for thorough legal research and analysis by certified IDR entities.

Avoid the Resubmission Cycle

If an initiating party fails to meet the minimum requirements for initiating a dispute or a dispute is incorrectly batched or bundled, the IDRE will request a resubmission. Both parties will receive a notification email, with the initiating party’s email including a link to a form for resubmission.

CMS recently changed the process for resubmitting incorrectly batched or bundled claims. Read more on the May 2024 change.

Knowing these common mistakes not only saves the time and headache of resubmissions but can also lead to better outcomes for fair resolutions.

For a detailed walkthrough of initiating a dispute, see How to File.

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