Partial Report on the Independent Dispute Resolution (IDR) Process October 1 – December 31, 2022 (Apr. 2023); DOL: Federal Independent Dispute Resolution Process – Status Update (Apr. 27, 2023)
The DOL, HHS, and IRS have jointly issued a partial report with usage data on the surprise billing independent dispute resolution (IDR) process created when the Consolidated Appropriations Act, 2021 (CAA, 2021) expanded patient protections to shield individuals from surprise bills for certain out-of-network emergency and non-emergency services. The CAA, 2021 and regulations addressing procedural aspects of plan payments to nonparticipating providers, including the role of certified IDR entities, require the agencies to post quarterly reports highlighting IDR activity (see our Checkpoint article). The data for the report is drawn from certified IDR entities and the HHS federal IDR portal, which opened April 15, 2022 (see our Checkpoint article). The DOL separately issued a status update on IDR activity. Here are highlights:
Partial Report. The agencies’ report covers the quarter from October 1–December 31, 2022. Because the report requires substantial manual processing, the scope of the report is limited and will be supplemented later. During this quarter, disputing parties initiated 110,034 disputes through the IDR portal, which was a 53% increase in dispute volume compared to the prior quarter. However, certified IDR entities made over three times more payment determinations during the quarter and closed more disputes overall compared to the prior quarter. The report highlights that the primary cause of delays in processing disputes has been the complexity of determining whether disputes are eligible for the federal IDR process, pointing out that non-initiating parties challenged eligibility in approximately 40% of initiated disputes during the quarter. A table lists the number of disputes initiated by state, while other tables track, for instance, disputes by type of service provided based on Current Procedural Terminology (CPT) codes, the top 10 initiating and non-initiating parties, and the reasons for closure.
Status Update. Between April 15, 2022, and March 31, 2023, disputing parties initiated 334,828 disputes through the federal IDR portal, of which 122,781 were challenged as not eligible. Of the disputes closed, 39,890 were ultimately determined ineligible. As of March 31, 2023, certified IDR entities made payment determinations in 42,158 disputes. Initiating parties were the prevailing party in nearly 71% of the disputes. Also noting that the primary cause of delays is the complexity of determining whether disputes are eligible for the federal IDR process, the DOL highlighted that data elements have been added to the dispute initiation form and the parties are now directed to attach documents supporting or contesting eligibility so that certified IDR entities have all required information.
EBIA Comment: The agencies advise that they are “considering additional policy and operational improvements, including through rulemaking,” to improve the process and increase the speed of payment of IDR determinations. The agencies have already increased the administrative fee from $50 to $350 per party for disputes initiated during the calendar year beginning January 1, 2023, explaining that the increased fee reflects the rising volume of disputes and additional expenditures associated with the agencies’ enhanced role in conducting pre-eligibility reviews (see our Checkpoint article). For more information, see EBIA’s Health Care Reform manual at Sections XII.B.3 (“Surprise Medical Billing: Emergency and Non-Emergency Services”) and XII.B.4 (“Surprise Air Ambulance Billing”) and EBIA’s Group Health Plan Mandates manual at Section XIII.B (“Patient Protections”). See also EBIA’s Self-Insured Health Plans manual at Section XIII.C (“Federally Mandated Benefits”).
Contributing Editors: EBIA Staff.