By: David Ostrowsky

The Independent Dispute Resolution (“IDR”) process was designed to be a cornerstone of the No Surprises Act (“NSA”), a means for resolving claims for payment for out-of-network items and services and a vital mechanism for buttressing the NSA’s protection for plan members against potentially devastating balance billing expenses. Unfortunately, since the NSA took effect on January 1, 2022, things have gone awry on many fronts.

The case volume has overloaded the IDR process; courts have been split over whether and how parties can enforce arbitration awards; payers, including group health plans, have paid close to four times as much for services as CMS rates. Ultimately, the confluence of these troubling dynamics  threatens to undermine the original intent of the NSA and elevate costs for all.

In fact, in the most recent edition of JAMA Internal Medicine, a prominent monthly peer-reviewed medical journal published by the American Medical Association, authors Kevin A. Schulman, MD and Barak Richman, JD, PhD, provided indisputable evidence that prices stemming from IDR decisions closely align with what providers – many of whom belong to private equity-backed practices -- have requested, vastly exceeding Medicare rates and prior in-network commercial market prices. As just one example, Schulman and Richman report median IDR decisions (from Q1 and Q2 2023) for three categories of services – emergency care, imaging, and neonatal/pediatric critical care – that surpass Medicare prices by a factor of 3.7 or more for all three service types. Clearly, the NSA has not curtailed exploitive business practices and at this time, there still aren’t any implementing rules in force, as arbitrators continue to operate with minimal substantive guidance in trying to resolve price disputes.

Subsequently, now, more than ever, it is of paramount importance to understand how such developments will impact your self-funded health plan. Handling NSA claims is, after all, still a relatively new process, one largely bereft of transparency, and many plans are understandably struggling to manage open negotiations and subsequent IDR procedures. In this regard, The Phia Group, with its battle-tested processes for deftly handling NSA claims and appeals and utilization of intelligent out-of-network pricing methodologies, benchmarking and cutting-edge appeal review software, can provide immeasurable value.

“Unlike the rest of the organizations in this industry that provide NSA services, our reputation was built on ensuring that all regulatory, compliance and plan design needs are focused on first,” explains Phia CEO Adam V. Russo. “This includes understanding the processes and tools that administrators have in dealing with the vastly different deadline and notification aspects of the NSA. We know it, we built our software around it and our extensive team of experts ensures that we meet every set of standards needed for a successful NSA program, including coordination of stop loss carriers. 

“There is no other firm with repricing capabilities that can match our reputation and outcomes when it comes to navigating the legal complexities that this service requires.”

Some of the core reasons why Phia’s IDR support service achieves optimal results:  

• Experts who over the past three years have developed an efficient process for handling NSA claims and can expeditiously manage critical documents involving communications (i.e., those to clients to facilitate informed decision making), billing, and evidence. In addition, strong familiarity with the NSA timelines and stages, so there is the ability to quickly prioritize without wasting time. Subsequently, procedural issues are resolved with strict adherence to timelines (i.e., deadlines to responding to IDR initial selection and submitting a final offer) 

• In addition to attorneys, case handlers who have the real-world procedural NSA experience to thoroughly comprehend benchmarks, coding, and evidence so they’re not going into any situation uninformed, even for complex high-dollar cases. Leveraging industry-standard coding, provider quality metrics, and offers grounded in indisputable, objective evidence reduces unnecessary costs while maximizing savings.

• Phia Ignite, a tool engineered to help health plans navigate the complexities of the NSA, including IDR, and mitigate financial risks by providing defensible payment strategies and supporting balance bill resolution work.

“With a powerhouse team of seasoned attorneys, certified medical coders, data-savvy analysts, and skilled negotiators, Phia is uniquely equipped to handle straightforward NSA claims with precision and seamlessly scale to expert-level solutions for the most complex cases,” added Scott Bennett, Phia’s Senior Vice President of Provider Relations.

Undeniably, the IDR process continues to be riddled with significant ambiguity and opacity but The Phia Group, for the aforementioned reasons along with many others, has the resources to help you navigate the chaos.