Backlogged IDR Process

idr process

With thousands more claims than expected and long wait times causing providers delays in reimbursement, It’s no surprise that the No Surprises Act’s IDR process and its serious shortcomings have caused a strain in the US healthcare system, which could lead to major repercussions. In this blog, you will find a collection of challenges providers are facing at the mercy of a slow, cumbersome IDR process.

Since the beginning of the No Surprises Act, providers have struggled to get the reimbursements they deserve for providing emergency, life-saving care. 

The federal IDR process was introduced to allow providers to dispute underpayments for this care and receive a fair rate for reimbursement. 

This has not been the case.

According to this article, “As of August 11th, mediators have decided just 1,200 out of 46,000 payment disputes submitted to the federal government.” (only 2.6%).

Arbitrators are incredibly backlogged, disputing claims healthcare providers need and deserve for their work while government entities are clearly overwhelmed and unprepared. Many arbitrators refuse to accept new cases, leaving providers stuck in the mud with no way to recover underpayments from insurance companies.

In the first nine months, results of the NSA have illustrated its heavy dependence on the IDR process. 

According to this article, a survey from Blue Cross Blue Shield Association and AHIP found that with 9 million averted surprise bills came 275 thousand arbitration claims. This was more than 10 times the anticipated amount.

Inefficiencies and extra costs stem from overuse and abuse of the IDR process, potentially leading to an increase in healthcare costs.

Fortunately, the federal IDR process is an optional method of recovering out-of-network revenue in emergent settings. Allia group offers an alternative approach to pursuing these claims.

With billing disputes piling up and lawsuits continuing to emerge, the No Surprises Act has left a growing backlog in claims and threatens to leave doctors without paychecks.

In this Bloomberg Law Deep Dive into surprise medical billing, director of Government Affairs at the Medical Group Management Association, Claire Ernst, explains “Some claims have been pending for eight or nine months. That’s eight or nine months that you’re not getting paid.”

Instead of relying on a slow IDR process in which arbitrators have to “reconsider methodologies” with every change to federal guidance, consider Allia Group’s alternative approach to challenging underpayments for your physician group.

Unsurprisingly, the No Surprises Act is challenging revenue cycle managers, with out-of-network claim rates favoring insurers and placing billing burdens on providers.

According to Head of Regulatory Affairs and Compliance at R1 RCM revenue cycle management services, Amber Thomas, payment could take years.

She states that her team of lawyers has been involved in speaking directly with CMS on the issue of the severe IDR backlog, calling the issue “a horrible policy failure.”

Thomas also points out that revenue cycle departments are not “programmed to meet the mandate of the rule to stop balance billing,” especially when insurance companies aren’t using coding correctly to inform providers when billing may be subject to the NSA.

When insurers do not code consistently, the burden once again falls on providers and hospitals.

If your practice’s revenue cycle needs assistance, reach out to Allia Group to get started recovering lost revenue.

Batching claims must also be reconsidered in the No Surprises Act’s IDR process.

Certain conditions must be met to submit a batched dispute for multiple qualified IDR items or services. Multi-qualified IDR items and services are included together in one payment determination as “bundled items and services.” Batched items and services must meet four requirements, as detailed in this article.

IDR entities deny cases for batched claim items if they are “incorrectly batched.” They demand that service codes are separated into separate disputes, as submissions cannot include multiple service codes from the same patient encounter as one dispute.

If a dispute is incorrectly batched, the IDR entity selects one service code to continue through the process and asks the moving party to resubmit other codes separately – creating more work and slowing down the process.

The Senate Finance Committee discusses the “big mess” of the IDR Process in this update from Beckers.

Insurers aren’t responding to the backlog of IDR claims in a timely manner (or sometimes not at all).

Even when providers win payment determinations, payers withhold reimbursement after the statutory deadline.

More legislative action is needed to curb the high number of claims and insure the NSA is being implemented in the way Congress intended.

Read more about the committee hearing, and reach out to Allia Group for a favorable revenue recovery alternative.


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