As IDR Volume Grows, Experience Matters

By: David Ostrowsky

The No Surprises Act (NSA) established a federal framework intended to protect patients from surprise medical bills while also providing a structured process for resolving payment disputes between payers and out-of-network providers and facilities. As the volume of disputes has grown, policymakers, employers, health plans, providers, and researchers have continued to evaluate the operational and financial impact of the statute’s Independent Dispute Resolution (IDR) process.

Recent analyses have highlighted the significant number of disputes being submitted through the federal IDR system and the substantial resources devoted by all stakeholders to administering and resolving those disputes. These developments underscore the importance of understanding the regulatory requirements, timelines, evidentiary standards, and strategic considerations associated with the NSA.

For employer-sponsored health plans and their administrators, effective NSA compliance requires more than simply participating in the IDR process. Success depends on accurate eligibility determinations, thorough documentation, well-supported negotiation and arbitration submissions, and adherence to evolving regulatory guidance.

The Phia Group’s Phia Unwrapped service assists health plans and plan administrators in navigating NSA compliance, open negotiations, and IDR proceedings. The program is designed to help clients manage complex out-of-network claim disputes through a process focused on regulatory compliance, documentation, cost analysis, and advocacy within the framework established by federal law.

Based on The Phia Group’s historical review of publicly available federal IDR determination data, matters supported through Phia Unwrapped have achieved favorable IDR outcomes at a rate that exceeds industry-wide published results. Past results are not guarantees of future outcomes, and individual dispute results depend on the specific facts, evidence, procedural posture, and applicable legal and regulatory considerations involved in each matter.

Adam V. Russo, CEO and Co-Founder of The Phia Group, stated:

“Our focus is helping health plans navigate the complexities of the No Surprises Act through a disciplined, compliance-driven approach. The NSA and IDR processes involve numerous regulatory and procedural requirements, and our goal is to help clients effectively present their positions, satisfy applicable requirements, and make informed decisions throughout the dispute-resolution process.”