By: Andrew Silverio

IDR Entities Still Struggling with Volume – Highlights from the Q4 2022 Report

Under the No Surprises Act (NSA), the Departments of Health and Human Services, Labor, and Treasury are required to post quarterly data on the Federal Independent Dispute Resolution (IDR) process.  In response to the federal court decision in Texas Medical Association, et al. v. United States Department of Health and Human Services, portions of the governing regulations were vacated, resulting in a February 10, 2023 order for IDR entities to cease issuing new payment determinations (see CMS payment disputes between providers and health plans).  This was lifted as of February 24, 2023 for services furnished before October 25, 2022, and as of March 17, 2023 for services furnished on or after October 25, 2022.   Because there was essentially a freeze on IDR proceedings for a good portion of Quarter 1 of 2023, the report issued for Quarter 4 of 2022, available at CMS Report, is the most recent and complete picture we have of how the process is performing.  The full report is certainly worth reviewing, but here are some noteworthy data points:

110,034 disputes were initiated in Q4 2022

• This is a 53% increase from Q3 2022
• The vast majority were for OON Emergency or non-Emergency items or services, with just around 6% (6,864 in total) being for OON air ambulance services

IDR entities closed our 31,714 disputes in Q4 2022

• Over three times more payment determinations were made (12,662) than in the prior quarter
• However, the total number of closed disputes is still just around 29% of the number of new disputes submitted in this same time period
• Of the 31,714 closed disputes, 12,662 (40%) reached a payment determination, while 9,525 (30%) were found ineligible for IDR proceedings

The overwhelming majority of proceedings (>99%), not surprisingly, were initiated by providers

A few entities are dominating the IDR Submission process, both as complainant and respondent

• One entity, SCP Health, initiated 30% of all disputes for OON emergency and non-emergency items or services
  • United Healthcare was the most frequent non-initiating party, at 25% of disputes
• One entity, Global Medical Response, initiated 42% of all air ambulance disputes
  • Zelis was the most frequent non-initiating party, at 12% of disputes

It will be important to keep an eye on how these data trends develop, and how the backlog caused by the work stoppage in quarter one of this year will impact new numbers.