Healthcare billing can be complicated, especially when there’s a disagreement between a health insurance company and a medical provider about how much should be paid for certain services.
That’s where Independent Dispute Resolution (IDR) comes in, a process that helps resolve these payment disputes fairly.
Why was IDR created?
The IDR process was established as part of the No Surprises Act (NSA), a law passed in 2020 to protect patients from Surprise Billing, defined as unexpected medical bills after obtaining items or services from an out-of-network (OON) provider, where the individual did not have the opportunity to choose from services covered by their health insurance or plan’s network (in-network provider).
How does the IDR Process work?
When a health insurer and a provider can’t agree on the payment amount for an out-of-network medical service, they can turn to IDR.
Both parties must participate in a 30-day Open Negotiation period. If the parties are unable to come to a payment agreement during the Open Negotiation period, either party can start the IDR process by submitting a formal IDR Initiation request through the CMS federal portal.
Once the request is filed, an Independent Dispute Resolution Entity (IDRE), a neutral third party, is assigned to review the dispute and will determine eligibility according to the NSA.
If the dispute has been determined eligible for the IDR process, both parties will be required to submit their best payment offer (Notice of Offer) and any supporting
documentation.
The IDRE will choose the offer that best reflects the value of the service based on key factors, as included in the NSA.
What parties can participate in the IDR process?
IDR can be used by:
- Out-of-network medical providers
- Facilities
- Air ambulance providers
- Health insurance companies.
What are the Timelines?
There are specific timelines to follow:
Looking for an Independent Dispute Resolution Entity (IDRE)?
National Medical Reviews is certified as an IDRE, with solutions with real people in real time.
Submit your dispute to the CMS portal here.
If you have more questions, contact us [email protected]
How does NMR handle cases?
Allowed by the NSA, a certified IDRE may consider multiple qualified IDR items or services jointly, related to the treatment of a similar condition, as part of one IDR payment determination.
This reduces the number of IDR proceedings, unnecessary complications from multiple single disputes between plans and providers, and streamlines certified IDR entity decision-making.
NMR accepts Batched disputes according to the CMS November 2023 Operations Proposed Rule, while meeting all the rest of the batching criteria:
- Single-patient encounter (single episode of care)
- Same Service Codes (all different patients)
- CPT Code Span Batching
How do I make a payment?
National Medical Reviews accepts multiple payment methods for both CMS Administrative Fees and the IDRE Service Fees. Parties may respond directly to the E-Invoice that is linked to the specific dispute under review.
This method requires no prior setup and provides for immediate payment reconciliation of the dispute. National Medical Reviews also accepts credit card payments, ACH, paper checks, and has Escrow options available.
What are National Medical Reviews’ differentiators?
- We have real people in real time monitoring every part of the IDR process, from receiving a dispute through the CMS Federal portal to the final resolution.
- Through our billing platform, we offer diverse payment methods.
What are the best practices for a successful Federal IDR Initiation?
- Notice of IDR Initiation Form
- Proof of open negotiation attempt (screenshots, emails, etc.)
- Plan Documents
- Proof of Payment (ERA, EOB, etc.)
- Qualifications and credentials of the provider who rendered service to the patient.
- Previously negotiated rates
- Know the difference between Federal and State. Check the Applicability Chart
- Notice of Offer
The IDR process provides a reliable path to resolving disputes by following clear rules, structured timelines, and utilizing the services of an expert Independent Dispute Resolution Entity.
