HHS received more than five times as many IDR submissions than anticipated

More payers and providers are using the independent dispute resolution (IDR) process than the government anticipated to settle payment for items and services covered by the No Surprises Act.

In a 2021 interim final rule, it was estimated that only 17,333 claims would be initiated through the IDR process per year. However, a recent report revealed 90,078 disputes were initiated between April 15 and September 30, 2022 alone. Nearly 80% of these disputes were initiated in the third quarter.

Of the total disputes, 86,807 were for emergency or non-emergency services and 3,271 were for air ambulance services. Healthcare providers submitted 84% of all disputes and facilities submitted 15%.

More than 20,000 claims were closed, according to the report. Out of these closed disputes, 15% resulted in a payment determination and 69% were found to be ineligible for the IDR process. IDR eligibility is based on factors such as state versus federal jurisdiction, correct bundling and batching, compliance with applicable time periods, and completion of open negotiation.

Most delays in processing disputes are due to the complexity of determining whether disputes are eligible for the federal IDR process, according to the report. Nearly half of all initiated disputes involved non-initiating parties challenging eligibility for the IDR process.

Eligibility determinations are conducted more quickly when submissions are complete and contain all of the necessary information, according to the report. Although CMS has already released guidance on disclosure requirements and submissions, additional technical information may be published in the future.

Texas, Florida, and Georgia initiated nearly half of the disputes, according to the report. These states are bifurcated, meaning they have specified state laws that could apply to items or services relevant to the IDR process. In September 2022, CMS released updated guidance on the applicability of IDR in bifurcated states to assist disputing parties and certified IDR entities.

Revenue integrity professionals should review CMS guidance on the No Surprises Act. If it’s necessary to initiate a dispute through the federal IDR process, ensure the item or service is eligible and the submission is complete. Be on the lookout for future reports and technical assistance on IDR eligibility, disclosure requirements, and submissions.

Editor's note: Find more NAHRI resources on the No Surprises Act here.