Resources   24th June

Unlocking Revenue Potential Through Federal IDR Process: An Overview

The recent report on the Federal Independent Dispute Resolution (IDR) Public Use File (PUF) for the last two quarters of 2023 provides significant insights into the Federal IDR process. This process, established under the No Surprises Act (NSA), offers a structured method for resolving out-of-network (OON) payment disputes between providers, facilities, air ambulance services, and health plans. The data highlights the importance and benefits of utilizing the Federal IDR process for maximizing revenue opportunities, especially for healthcare providers and associated services.

Key Highlights from the Federal IDR PUF Report
  1. High Volume of Disputes and Outcomes:

    • In the last six months of 2023, 390,346 disputes were initiated, marking a 35% increase from the first half of the year, despite a temporary suspension of the portal operations due to court orders.
    • Overall, 679,156 disputes were initiated in 2023, more than tripling the number from 2022. This surge indicates a growing reliance on the IDR process for resolving payment disputes

  2. Increase in Payment Determinations:

    • Certified IDR entities made 125,478 payment determinations in the second half of 2023, a 50% increase from the first half. Overall, 209,346 determinations were made in 2023, a significant rise from 16,238 in 2022.
    • Providers and facilities won the majority (82%) of these disputes, emphasizing the effectiveness of the IDR process in favor of healthcare providers.
  3. Efficiency and Scalability:

    • Despite operational challenges and temporary suspensions, certified IDR entities scaled up their operations to handle the high dispute volume efficiently.
    • The Departments overseeing the IDR process continuously implemented technical and operational improvements, enhancing the overall throughput and compliance with court rulings

  4. Eligibility and Process Improvements:

    • Determining eligibility remained a complex task, with 37% of disputes facing eligibility challenges. However, improvements in the dispute initiation form and technical assistance have streamlined this process.
    • The consistent provision of required information at initiation has expedited the review and eligibility determination, aiding faster dispute resolution.

  5. Financial Impact and Prevailing Offers:

    • In 88% of payment determinations, the prevailing offer exceeded the qualifying payment amount (QPA), with providers frequently benefiting from higher payment offers.
    • This trend highlights the financial advantages for providers who engage in the IDR process, potentially increasing their revenue through favorable dispute outcomes.

Why Providers Should Leverage the Federal IDR Process
  1. Revenue Maximization:

    Engaging in the Federal IDR process can substantially increase revenue for healthcare providers. The high success rate (82%) for providers in dispute determinations underscores the potential financial gains from participating in this process.

  2. Transparency and Fairness:

    The structured and transparent nature of the IDR process ensures fair resolution of disputes. Providers can expect a standardized approach to payment determinations, reducing uncertainties and fostering trust in the system.

  3. Operational Efficiency:

    The ongoing improvements and scalability of the IDR process mean that disputes are handled more efficiently, reducing the time and resources spent on prolonged negotiations. This efficiency allows providers to focus more on patient care and other operational priorities.

  4. Legal and Regulatory Compliance:

    Staying compliant with the No Surprises Act and leveraging the IDR process ensures that providers are legally protected and can avoid potential penalties associated with out-of-network billing disputes.

  5. Strategic Advantage:

    Proactive engagement in the IDR process positions providers advantageously against competitors who may not be utilizing this resource. The data-driven insights and outcomes from the IDR process can also inform better negotiation strategies with payers.

Conclusion

The Federal IDR process, as detailed in the latest PUF report, presents a significant opportunity for healthcare providers to enhance their revenue streams through effective dispute resolution. By understanding the benefits and strategically engaging in this process, providers can ensure fair payment for services rendered, leading to improved financial stability and growth. We encourage providers to leverage the Federal IDR process to capitalize on these advantages and drive their revenue forward.