2026
Quarterly Newsletter

Service Focus of the Quarter: NSA/IDR

At first glance, the federal Independent Dispute Resolution (IDR) process sounds simple: The provider submits an offer, the plan submits an offer, and the IDR entity picks one. Unfortunately, though, almost nothing leading up to (or following) that decision is simple. Before anyone reaches IDR, the plan must determine whether the claim is subject to the No Surprises Act, support its initial payment and QPA, track multiple deadlines, and engage in open negotiation. A mistake at any one of those stages can cost the plan a loss before the merits are even considered.

The Phia Group’s NSA support service is designed to manage that process as one all-encompassing strategy. Phia Ignite implements the reimbursement methodology defined by the client, while our attorneys, certified coders, clinical staff, data analysts, and expert negotiators evaluate NSA applicability, identify procedural defects, develop multifactor support, negotiate with the provider, and prepare and manage the IDR submission if necessary. The plan remains the ultimate decision-maker, but Phia’s multidisciplinary team provides the evidence, support, and practical guidance needed to make that decision intelligently.

The results speak for themselves. Based on Phia’s historical review of publicly available federal IDR data, our supported matters have produced 2.5 times more NSA savings and three times more NSA wins than the industry average. For health plans, the difference isn’t just about getting through the process but protecting plan assets while doing it.

Contact sales@phiagroup.com to learn more about Phia’s NSA and IDR support services.

Enhancement of the Quarter - Clinical and Coding Expertise in IDR

Providers frequently argue that patient acuity, case complexity, and the resources used to provide care justify a higher IDR offer. Those arguments can’t always be countered with a rate table or payment benchmark alone.

The Phia Group continues to strengthen its NSA support service by bringing clinical and coding expertise directly into the IDR advocacy process. When the medical record matters, Phia’s clinical coding analysts can review the patient’s symptoms, diagnoses, billed services, E&M codes, tests, and resource utilization to test the provider’s clinical narrative against the actual record rather than accepting it at face value. We then translate those findings into evidence that the IDR entity can evaluate.

IDR advocacy is strongest when the financial, procedural, and clinical records tell one coherent story; Phia now brings all three to the table.

Phia Case Study

An air ambulance provider initiated open negotiation with one of Phia’s clients. These claims are notoriously difficult to resolve; air ambulance providers frequently offer only minimal, if any, reductions from billed charges, and many are unwilling to engage in meaningful negotiation at all. Notably, this has always been the case, even long before the NSA.

With the 30-day negotiation period already running, Phia immediately obtained the client’s approval and submitted an initial offer. The provider responded with a counteroffer that was more reasonable than is typical for an air ambulance claim, signaling that there was a genuine opportunity to resolve the dispute, which Phia later discovered may have been due to the provider’s unrelated recent loss at IDR. After a brief exchange of additional arguments, Phia negotiated a final settlement at approximately 55% of the original billed charges.

The plan saved more than $28,000, avoided the fees and unavoidable uncertainty associated with IDR, and established a constructive relationship that may make future negotiations with the provider easier, and could even potentially result in one of the most favorable ongoing air ambulance contracts in the client’s history.

In the current climate, IDR victories for the plan are always worth celebrating, but the best IDR outcome is often avoiding the proceedings altogether. Open negotiation is more than just a waiting room before IDR; handled properly, it can be where the dispute actually ends.

Fiduciary Burden of the Quarter

Federal law can’t predict whether a health plan will win any particular percentage of IDR disputes, nor could ERISA have possibly anticipated that almost 50 years after its inception, the NSA process would begin to require plans to pay benefit amounts far in excess of what the health plan actually provides. In other words, we have no reason to think that losing an IDR dispute is a fiduciary problem for the plan. But, a loss still doesn’t excuse negligent handling by the plan.

A plan may certainly delegate its NSA and IDR work, and practically speaking it’s almost always a TPA or other vendor handling open negotiation and IDR procedures on the plan’s behalf, but the plan shouldn’t simply send disputes to a vendor and never ask what happened. Fiduciaries need to understand which matters were resolved during open negotiation and which made their way to IDR; which IDR proceedings were resolved in favor of the provider and how much that translates to in extra payments from the plan; what fees were incurred; and whether recurring losses resulted from the merits of the disputes or preventable procedural and evidentiary problems. That information helps the plan determine whether its initial payment strategy is defensible; whether its vendor is identifying eligibility defects; whether its offers are supported by meaningful evidence; and whether certain providers or claim types require a different approach.

Crucially, it also gives the plan fiduciary a record showing that it selected and monitored the process with plan assets and participant interests in mind. The plan, after all, remains accountable for its vendors’ actions taken on behalf of the plan, which is something that ERISA and its implementing regulations have always assumed; the plan certainly isn’t required to manually handle all plan functions itself, but the plan still remains responsible for outcomes, even when the underlying process was delegated to a vendor.

So, losing at IDR isn’t inherently a fiduciary problem, but the burden is to make sure the plan isn’t walking in blind. With IDR volume continuing to increase, the use of an unexamined process is itself an increasingly dangerous fiduciary decision.