Kaitlin Howard

By Kaitlin Howard

Kaitlin Howard is a researcher and writer producing insightful content across the healthcare revenue cycle. She has written and produced content for Zelis, Waystar, and Recondo Technology, as well as agencies. With a B.A. in English and Writing from University of Denver, Kaitlin stays current on market updates on claims management and healthcare payments, publishing a regular educational blog series on industry trends and Zelis offerings.

Simply put, the independent dispute resolution (IDR) procedure is tricky.

That’s why we had Matthew Albright, Zelis Chief Legislative Affairs officer, Lisa LaMaster, Zelis Vice President of Business Solutions, and Tristan Buis, Zelis Director of Claims Settlement sit down with the Future Healthcare today podcast, hosted by Kevin Tierney, to shed some light on what payers can expect in the near future as IDR continues to change the way payers and providers interact.

As always, we’ll discuss the highlights below, but you can listen to the full podcast here:

A Quick Recap

Starting January 2022, consumers have new billing protections when receiving emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers.

These new rules (we’re looking at you, No Surprises Act) ensure excessive out-of-pocket costs are restricted and emergency services are covered regardless of whether a provider is in-network.

Previously, an out-of-network provider could bill consumers for the difference between the charges billed and amount paid (aka balance billing).

The “No Surprises” rules create new protections against balance billing and establish a new process, called independent dispute resolution (IDR), which providers, facilities, and health plans can use to resolve payment disputes for out-of-network charges.

Let us explain.

Say a provider receives an initial payment for payer-allowed charges on an eligible NSA claim. The provider has 30 days to start an open negotiation period with the payer. When those 30 days are up, if the payer and provider or facility haven’t agreed on a payment amount, either party has 4 days to initiate the IDR process using the federal IDR portal.

The IDR process typically goes as follows:

  1. The parties agree upon a third-party arbitrator, or let the selection fall to the HHS. This is known as a certified IDR entity. They will be in charge of deciding the final payment amount.
  2. Both the provider and the payer then submit payment offers to the IDR entity, as well as any additional information in support of their offer.
  3. The IDR entity selects from the two disputing parties’ offers. The provider and plan must abide by the entity’s decision. Payment is made within 30 calendar days of the decision.

To start the process, you must have:

  • Information to identify the qualified IDR items or services
  • Dates and location of items and services
  • Type of items and services (e.g. emergency and post-stabilization services)
  • Codes for corresponding service and place-of-service
  • Attestation that items or services are within the scope of the Federal IDR process

Main Focus for Payers

The IDR process boils down to two main friction points: managing timelines and paying fees.

Organizations need to ensure they have good communication with everyone involved.

And that comes down to picking the right solutions vendor.

The first critical timeline involves the initial dispute of the provider. Your chosen vendor should track whether a provider has submitted the initial dispute for open negotiation in a timely manner, as well as if they detailed why they deserve payment above the qualifying amount originally issued to the claim.

But one of the vital areas of support is during the open provider negotiation period. With full engagement from your vendor, as well as the provider, your organization could potentially settle outside of the IDR process. Which sounds like a win-win if you ask us.

Upcoming Challenges

Take into consideration the recent Texas lawsuit regarding the NSA’s IDR process. Any large lawsuit decision could challenge the same arbitration factors yet again, or determine different elements of the IDR process.

There have also been whispers of a final rule, which could reiterate the current process or change how or why the arbitrator makes their decision.

The Wrap Up

Regardless of your current processes and opinions, there seems to be quite a storm coming with the new IDR process. And although we can’t exactly predict the weather, we do recommend you bring an umbrella just in case.

If you’re interested in finding out how Zelis can support your organization during these unprecedented times, connect with us here.