Outlier Claim, Outstanding Outcome: Phia Secures Major Win in NSA Dispute

A client engaged Phia to assist with a claim that had progressed to the final stages of the No Surprises Act (NSA) process. Open negotiations had been completed, and the Independent Dispute Resolution (IDR) filing had already occurred. The IDR offer submission was due when the file was referred to Phia.

 

The claim was substantial, with billed charges exceeding $500k. Research on market data for the applicable DRG reflected a rate of only $27k. Due to the patient’s 22-day inpatient stay, the long period of stay marked this claim as a clear outlier (outliers can be analyzed on reasonable cost due to the problems with standard case-based analysis like a DRG benchmark).

 

In preparing the IDR response, Phia highlighted that the DRG-based market benchmark was only $27,000 and then focused on the provider’s own cost data as a public and credible benchmark for the plan’s offer. Phia emphasized that the Plan’s offer represented a significant and reasonable adjustment due to the claim’s outlier nature, the cost based analysis, and the provider’s own publicly reported costs as a credible benchmark.

 

The IDR entity ultimately ruled in favor of the Plan. The provider’s offer was $143,000—nearly $80,000 more than the Plan’s submission.

 

By partnering with The Phia Group, the client achieved a favorable IDR decision, saving more than $430,000 off billed charges and prevailing in a high-stakes negotiation with a major health provider system.