As we progress further into the new year, many of the proposed changes that we’ve documented over the past year are coming into effect. Today, we’re going to examine a specific part of the insurer-payee relationship as it stands in 2022: IDR, or Independent Dispute Resolution.
To quickly define our terms, IDR is a process by which payment disputes are resolved between insurers and out-of-network providers. After a payment has been disputed, both the insurer and the out-of-network provider are required to submit a proposed payment amount to a neutral arbiter. From there, the arbiter decides a payment amount, which is typically binding.
Prior to the No Surprises Act, only nine of the thirteen states with comprehensive surprise medical bill protections had adopted IDR, with other states implementing the practice in other areas. Now that the No Surprises Act is the law of the land, there is expanded access for both insurers and out-of-network providers to use federally-recognized IDR services. Here’s what that looks like for parties that are subject to the federal law.
Before the process can even begin, both parties must initiate a 30-business-day “open negotiation” period with the stated goal of determining a payment rate. Only if the parties fail to come to an agreement on the payment amount during this period can either party take the next step of beginning the IDR process.
Once the move has been made to begin IDR, the two parties must jointly agree upon a certified independent dispute resolution entity. This entity must in turn confirm that they are truly neutral and will not favor either party over the other. If the parties cannot agree upon a certified independent dispute resolution entity, or if the entity is found to hold bias in the case, the Departments will take it upon themselves to select an independent dispute resolution entity to handle the case.
After the selection has been made, the IDR process moves along in the manner described above. Both parties offer their proposed payment along with supporting documentation — and once all of the data has been collected and evaluated, the arbiter makes a binding judgement to determine the out-of-network payment amount.
This process is not free. First, both parties must pay an administrative fee of $50 each (as of 2022). After the resolution of the dispute, the non-prevailing party must also pay a “certified independent dispute resolution entity fee”; as of 2022, the fee ranges from $285 to $500 for single claims and from $450 to $670 for batched claims.
It should be noted that the new law has listed clear and strict deadlines for every step of this process. The timeline for IDR is as follows:
1. 30 business days: After the initial payment or denial of payment, either party has the option to begin the 30-business-day open negotiation period, where parties can reach a joint agreement of payment to avoid IDR.
2. 4 business days: If the open negotiation fails, either party has four business days to initiate IDR.
3. 3 business days: After the IDR process has been initiated, both parties have three business days to agree upon a certified independent dispute resolution entity.
3a. 6 business days: If bias is discovered or the parties fail to reach an agreement, the Departments will select a certified independent dispute resolution entity within six business days of the independent dispute resolution initiation date.
4. 10 business days: Following the agreement upon, or assignment of, an independent dispute resolution entity, both parties have ten days to submit payment proposals and supporting documentation to be considered.
5. 30 business days: Within 30 business days of the certified independent dispute resolution entity’s selection, a payment determination will be made.
6. 30 business days: When the payment determination is made, the payment must be submitted within 30 business days.
This may all seem well and good — but this doesn’t answer the question of how one actually starts the arbitration process. You may also be asking, where does one locate an IDR entity? And what is the process for becoming an IDR entity?
Let’s go through those questions in order. Unfortunately, how one actually begins this process is still a little unclear. However, CMS aims to resolve this with technical training on how to use the IDR system. Additionally, CMS is planning webinars and meetings that will take place in the coming weeks to review this information. If you have questions about this, you can email firstname.lastname@example.org or call the NSA Help Desk at 1-800-985-3059 between 8 a.m. and 8 p.m. EST, 7 days a week.
As far as a list of IDR entities is concerned, CMS has made it easy. There’s a list of certified IDR entities on their website here, and the list will be continually updated as more entities are certified. Providers and insurers have had experience working with one of these certified entities, Maximus, at the state level in Florida and Georgia.
Addressing the final question, CMS has also not fully defined this process. However, they say they are developing a portal for organizations to apply to become certified independent dispute resolution entities, with more information coming out about that in the coming months.
This is what IDR looks like in 2022 — expanded access to federal IDR, strictly defined timelines, and more. As with all things in this area, we will keep you up-to-date as CMS rolls out its IDR tools and as the process itself changes.