2025
Quarterly Newsletter

NSA/IDR

September marked the ninth consecutive month in which Phia Ignite – Phia’s proprietary technology supporting client-defined payment methodologies – has helped clients save an average of over 80% off out-of-network billed charges. Phia’s services are not just about process, but outcomes: our dedicated NSA support team has numerous documented wins, including IDR decisions that have cut hundreds of thousands of dollars off billed charges, while also yielding measurable savings at the open negotiation stage to avoid IDR altogether. In fact, within IDR, we’re proud to boast that our seasoned team of experts and Phia Ignite have secured 2.5 times more savings, and 4 times more wins, than the industry average.

Powered by Phia Ignite, The Phia Group delivers a turnkey No Surprises Act strategy that starts at the first dollars spent on a given claim and continues to provide support through a final IDR award (or even after, in some cases). We triage each NSA claim, calculate a defensible initial payment based on plan parameters, and manage open negotiations with data-backed QPA support and multifactor benchmarking – always subject to the plan’s approval. Then, if negotiations stall, we prepare and manage the full IDR submission and correspondence, keeping the process simple, straightforward, and stress-free.

Since IDR rules and throughput keep shifting, Phia’s legal team stays on top of evolving trends and compliance bottlenecks so plans aren’t left confused, waiting, or overpaying.

Enhancement of the Quarter: Independent Dispute Resolution Support

Our Provider Relations team has been working diligently to standardize a front-end vetting process for high-dollar professional claims, especially neuromonitoring. Our team of experts now scrutinizes technician vs. physician status and cross-checks whether the same practice has already pushed a parallel physician claim into IDR for the same patient/DOS.

We’ve also built in a procedural screen designed to catch in-network and elective services, non-emergent professional claims, and filings outside applicable timelines before they advance to avoid unnecessary headaches for health plans in dealing with improper IDR submissions. Our team now confirms facility network status directly with the client at intake, a change that has resulted in many voluntary withdrawals and IDR dismissals; this shifts Phia’s IDR support services from defense to proactive prevention, saving adjudication time and limiting exposure and resource expenditures to proper QPA-level outcomes.

Phia Case Study: Neuromonitoring No-Nos

Our IDR Support team received a neuromonitoring claim exceeding $60,000. Our team’s front-end review flagged that the billing NPI belonged to a technician rather than a physician, which was the first clue that something was amiss. Digging deeper, we found the same practice had already submitted the neuromonitoring physician’s claim to IDR for the same patient and date of service. We documented both issues in our submission to the IDRE, which ultimately awarded every line at the QPA (just a few hundred dollars per line) rather than the provider’s demand.

Using the same playbook on other matters, we have been able to avoid adverse determinations to begin with, rather than receiving finalized IDR determinations and then challenging them. Our proactive approach has saved plans countless headaches, hours of effort, and worries about noncompliance by not paying an IDR award even though it was clearly flawed.

Fiduciary Burden of the Quarter: Following Medicare COB

When plan members reach Medicare-eligibility age, it’s very tempting to want to shift them onto Medicare. The problem is that the federal government is aware of that and has taken active steps to make sure it doesn’t happen. Specifically, the law prohibits a health plan from requiring or incentivizing members covered by virtue of active employment to enroll in Medicare. Plans are further barred from “taking into account” Medicare eligibility or entitlement, whether in the form of offering different premium levels, different benefits, penalties for non-enrollment, or anything else.

Many have suggested that simply coordinating benefits with Medicare does not run afoul of the Medicare Secondary Payer Act – and they are right! When an individual is enrolled in both the group health plan and Medicare, the two should coordinate with one another pursuant to the applicable federal rules. However, if an individual is not enrolled in Medicare, then there is nothing to coordinate with, and so “coordinating” with Medicare when Medicare isn’t actually a payer is just another way to say, “reducing benefits for individuals that are eligible for Medicare but who have not enrolled”. That’s a penalty, and it’s expressly not allowed.

Plan fiduciaries must act solely in participants’ interests and pay benefits in accordance with plan terms, but only to the extent those terms comply with law. Applying benefit reductions on the basis of Medicare eligibility typically constitutes breaching the duties of loyalty and prudence, invites Medicare Secondary Payer Act penalties, and can create “hard gaps” when stop-loss underwrites and applies limits the plan itself cannot.

If you have – or even think you have – noncompliant Medicare COB language, please contact The Phia Group as soon as possible!