Staying in compliance with the No Surprises Act (NSA) has been difficult for payors and providers alike, especially when it comes to the Independent Dispute Resolution (IDR) process. Here are some top challenges we’ve encountered, and what you can do to stay ahead of them.
Is this even my claim?
The IDR portal does not make navigating the world of the NSA easy. In fact, non-initiating parties cannot see most of what the initiating party posts. This leaves payors to identify claims with very little information. Providers also have difficulties navigating the No Surprises Act and getting claims to the right party when they initiate arbitration. This is true whether the payor handles NSA compliance or a vendor does.
Is this claim even eligible?
IDR submission rules are complex. As a result, many submitted claims aren’t even eligible for the IDR process. But the tight timelines associated with IDR make it difficult to vet submissions and object in time. At MultiPlan, 23% of cases we receive are ineligible for the IDR process, meaning payments already made should be considered final.
Complying with the No Surprises Act… on a tight timeline
NSA and IDR timelines are tight. It takes a lot of work to evaluate claims for eligibility and to create briefs that are comprehensive and compelling. While we have found that IDR entities may extend those timelines for providers, payors typically risk a default decision in favor of providers if they don’t submit briefs in time.
Where did all the IDR entities go?
IDR entities are the linchpin of the NSA process, as they are the organizations that determine the final payment amount. CMS, however, has certified only 13 organizations as IDR entities—and those entities aren’t always available to have cases assigned. Additionally, these 13 organizations handle a caseload that is nearly fourteen times greater than planned for. In fact, between April 15, 2022 and March 31, 2023, 334,828 disputes were initiated through the IDR portal.
What are the NSA IDR rules exactly?
When the NSA went into effect, IDR entities were instructed to use the qualified payment amount (QPA) as the basis for their final determinations. Payors, therefore, invested significant time and effort in building QPA schedules and applying them. After the Texas Medical Association (TMA) challenged various provisions of the NSA in court, however, the QPA is no longer the most important factor in final decisions. This rule change and others have forced payors to continuously overhaul systems and processes. Payors rightfully ask themselves how to comply with the NSA when the rules keep changing.
Hey! No favorites!
Our experience shows that IDR entities accept provider offers more frequently than payor offers. Some IDR entities are particularly partial to providers. This is especially frustrating when some of those provider offers are many multiples of the QPA, which should represent fair reimbursement.
Again, what are the rules?
Some providers have figured out that by subverting the rules of the IDR process, they are more likely to get their desired outcome. For example, they may flood the system with submissions. Payors then don’t have time to properly evaluate claims for eligibility and challenge them. If the claims are eligible, payors don’t have time to create offers that an IDR entity will accept. Additionally, NSA envisioned that most disputes would be resolved within the open negotiation period. Some providers, however, are not working collaboratively to arrive at a mutually agreed upon reasonable reimbursement. Instead, they are simply waiting out the 30 days until they can file for arbitration. They then demand a very high percentage of charges.
So what’s a payor to do when faced with No Surprises Act IDR challenges?
Prioritize eligibility reviews
At MultiPlan, more than one quarter of the cases for which IDR is initiated are actually ineligible. It takes a lot of work to evaluate claims for eligibility, which disadvantages the noninitiating party. You should focus on evaluating claims, however, since payment rendered on ineligible claims to date can be considered final.
Track EVERYTHING
And we mean everything. Which providers are accepting your initial payments and which aren’t? Are some providers consistently working collaboratively with you in open negotiations? Which arbitrators are giving you favorable rulings? Additionally, comprehensive reporting can help you manage tight timelines so you don’t miss key dates.
Don’t just stand on QPA
QPA was meant to establish a fair reimbursement for out-of-network providers. To be truly fair, however, you DO have to consider that no two providers, patients or facilities are identical. The QPA is a median, and there are times it is appropriate to increase reimbursement beyond it.
Another reason to go beyond the QPA is that providers have successfully challenged the use of QPA in IDR. This renders it less effective as the benchmark for fair reimbursement that lawmakers intended. Accordingly, QPA holds much less sway over the IDR entity’s determination process.
Given this situation, payors should make every effort to resolve the claim during the open negotiation period. They should go beyond QPA and establish negotiation rules and dynamic ceilings that vary by claim components, specialty and geography. This will give credibility to your offers and help you avoid the IDR process.
Help the IDR entity help you
IDR entities are buried in cases, with little time to dig into details. Include visual representations of your arguments, such as charts and graphs of key benchmarks and metrics. This allows IDR entities to quickly understand your arguments and rule in your favor.
Choose IDR entities wisely
If you’ve been tracking the outcomes of your IDR claims, you should have a good idea of which IDR entities are more likely to consider a payor’s position. Use that knowledge to your advantage.
Use predictive analytics wisely
Nobody has a crystal ball that will tell you with 100% certainty the prices providers and arbitrators will accept. But, with advanced analytics and predictive modeling, we can get close to predicting which offers will succeed.
Learn more about MultiPlan’s end-to-end NSA services and how we help clients overcome these common challenges.
