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Insurance Dispute Resolution: The Benefits of Arbitration

By May 28, 2024June 3rd, 2024No Comments

To make these goals a reality, Congress created the Independent Dispute Resolution (IDR) process by which providers and payers could arbitrate payments disputes, which prevents beneficiaries from receiving surprise medical bills and furnishes a final resolution for payment disputes.

The Federal NSA IDR has three main audiences: patients, payers, and providers. For each group, IDR has resulted in positive benefits.

For patients, the NSA has been estimated to have prevented a minimum ten (10) million surprise medical bills in 2023 with an ever increasing number of surprise bills prevented each year (over 1 million per month).

Patients are held harmless from receiving OON services, particularly in emergency situations, where immediate care is most important regardless of the provider’s status with the patient’s health plan.
For providers, insurance billing disputes and unresolved payment issues can affect the financial stability of their practice and potentially impact their ability to provide quality care to patients.

For payers, strained relationships with providers impact the patient experience and divert attention from finding cost-effective healthcare outcomes.

Jointly, the NSA offers payers and providers the opportunity for cost-saving settlements and arbitrations rather than resorting to lengthy and costly legal battles.

That is where IDREs like FHAS step in to arbitrate and provide efficient, trustworthy solutions to both providers and payers, effectively reducing the strain inherent in medical insurance disputes and out-of-network payment negotiations.

The No Surprises Act (NSA) established a structured framework for resolving surprise medical billing disputes in a fair and streamlined manner.

In the public eye, the act has focused on the benefits to the patients who were historically hit with large, unexpected medical bills (referred to as balance billing) — often for medical emergencies and other out-of-network medical care at an in-network healthcare facility.

This includes a range of medical services, including emergency care, anesthesiology, pathology, radiology, neonatology, services provided by assistant surgeons, hospitalists, intensivists, diagnostic tests like radiology and lab work, as well as out-of-network care when no in-network provider is available.

This legislation now puts the onus on the physicians, medical groups, and facilities to reach an agreement with the patient’s health plan on appropriate payment for these services. This can prove challenging, as providers seek timely payment for their services while health plans strive for fair pricing based on market rates and other relevant factors.

An IDRE ensures the necessary information to make a determination is collected from both sides, and CMS guidelines are carried out for fair opportunities for both parties to participate equally in the process and make their case.

FHAS stands out as a certified Independent Dispute Resolution Entity (IDRE) under the No Surprises Act, providing impartial and efficient resolution of payment disputes between healthcare providers and health insurance plans for out-of-network services.

With a focus on fair outcomes and compliance with legal requirements, FHAS ensures that both parties benefit from transparent resolutions. With years of expertise and streamlined processes, FHAS stands out for its exceptional productivity, consistently closing more disputes than received each month. FHAS is dedicated to following CMS-dictated timelines to deliver timely payment determinations.

FHAS actively enhances the effectiveness and fairness of dispute resolution by ensuring the NSA process is followed while providing feedback to CMS on a regular basis to get clarification and address gaps in the still-new process.

With an efficient end-to-end system and comprehensive approach, FHAS aims to streamline the burdensome out-of-network medical provider-payer payment disagreements, ultimately building trust and confidence in the resolution process.

Arbitration utilizing an IDRE maintains transparency throughout the dispute resolution process.

  1. Impartiality: Arbitration ensures that both sides get to advocate for their position and the resulting decisions are based solely on the merits of the case. This impartiality helps all parties understand the reasoning behind the resolution.
  2. Timeliness and Efficiency: Arbitration offers a timely and efficient alternative, providing clear timelines that expedite the resolution process. By avoiding prolonged back-and-forth negotiations, parties can swiftly reach resolutions, minimizing both time and resources.
  3. Financial Benefit: Without successful arbitration, providers may face delays or even non-payment, making arbitration a critical step in securing timely reimbursement. Allowing time for arbitration can help payers and providers feel assured that any service fee discrepancies are carefully reviewed against market rates and other factors for fair compensation, sidestepping drawn-out and expensive legal proceedings.

An IDRE is well-equipped to handle the nuances of various types of insurance payment disputes, ensuring resolutions are accurate and adhere to industry standards. FHAS brings years of specialized expertise to this process through arbitration, with arbitrators who possess decades of healthcare adjudication experience and training from the American Health Law Association.

Arbitration has a number of benefits for both providers and payers.

  1. Fair Compensation: By engaging in arbitration through a company like FHAS, providers can secure fair compensation for the medical services they render. This ensures that their efforts are appropriately recognized and compensated, leading to financial stability and sustainability for their practices. FHAS prides itself on rendering timely payment determinations, with over 100,000 payment determinations rendered in the past year within the applicable timelines.
  2. Consistent Payment Terms: For payers, using arbitration with an experienced company like FHAS helps maintain fair and efficient payment processes. Insurance companies and other payers can mitigate prolonged disputes, allowing for more consistent payment terms for out-of-network services. Participating in arbitration shows that payers value fair resolutions and working well with healthcare providers. This cooperation also aligns with the underlying goals of the No Surprises Act, encouraging providers and payers to prioritize in-network agreements for smoother negotiations.

Entities like FHAS play a vital role in promoting fair and efficient arbitration processes and independent dispute resolution. FHAS has solidified a reputation for providing a neutral and impartial platform for businesses to resolve disputes.

Customers appreciate FHAS for its lower fees, ease of operation, and consistent status updates. The company’s accurate eligibility determinations, contributing to a smoother dispute resolution process, reflect its dedication to providing exceptional service and value to its customers.

By looking to arbitration, both providers and payers can contribute to a more equitable and effective healthcare system for all parties involved.

Contact us today to learn more about our IDR services.

 

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