The healthcare industry is no stranger to acronyms, with new ones being introduced every single year. One of the most prevalent acronyms getting tossed around over the last few years is IDR. But what does IDR stand for, and how does it impact your revenue cycle?
Independent dispute resolution (IDR) helps resolve payment disputes between healthcare providers and insurance companies. IDR plays an essential role in ensuring fair reimbursements as your organization continues to address surprise billing and pricing transparency.
Let’s further unpack the question, “What does IDR stand for?” and explore how it works so you can recapture lost revenue.
Independent dispute resolution is a structured arbitration process used to settle disputes between healthcare providers and insurers when they cannot agree on payment rates for out-of-network services. It is particularly relevant in cases involving surprise medical bills, where a patient inadvertently receives care from an out-of-network provider.
Through IDR, a neutral third-party arbitrator evaluates the dispute and determines the appropriate payment amount. They will consider prevailing rates, the complexity of services, and prior contracted rates. This process ensures fair compensation for providers while preventing excessive patient financial burdens.
A provider or payer will typically invoke IDR when they fail to reach an agreement on reimbursement rates for out-of-network services. This process is essential for preventing prolonged disputes that can delay payments and disrupt a provider’s cash flow. The basic steps in the independent dispute resolution process are as follows:
Involved parties must exhaust open negotiation before initiating an IDR. The open negotiation window lasts for 30 business days. After open negotiations end, either party has four business days to begin the IDR process. Parties then have 10 days to choose a certified IDR entity and submit payment offers.
The IDR entity will arbitrate the matter and pick one of the two offers within 30 business days. After the entity has chosen an offer, the payer has 30 calendar days to submit additional payments.
The No Surprises Act was enacted to protect patients from unexpected medical bills. The act has made IDR a crucial mechanism for resolving out-of-network billing disputes. The law ensures that patients are not held financially responsible for surprise medical bills beyond in-network cost-sharing amounts.
Several new federal rules are slated to take effect in 2025. These proposed rules are designed to speed up IDR and expand on the protections of the No Surprises Act. Here are the proposed changes:
The new rules will require payers to provide additional information when issuing payment and denial notices, including:
Make sure that your payer partners provide the correct contact information so you can avoid delays in the dispute resolution process.
Proposed rule changes also include a new mandate that would require parties to submit an open negotiation notice via the Federal IDR portal. The notice must include specific details about the services provided and why the claim was denied.
Under current rules, batching policies vary by payer. If the new rule changes are approved, you can batch certain services related to the treatment of a similar condition. This will save time during the dispute process, as you can batch up to 25 items together.
Currently, the No Surprises Act doesn’t establish a deadline for determining if a dispute qualifies for the Federal IDR process. The proposed rule changes will set a five-business-day deadline for making eligibility determinations.
If approved, the rule changes will mandate that administrative fees are collected directly from the disputing entities, not through certified IDR entities. Continue to make administrative fee payments as usual unless the changes are approved.
Currently, you can request extensions for IDRs via the Federal IDR portal. However, the proposed rule changes will change the special circumstances that allow you to extend the time periods.
Now that we’ve unpacked the question, “What does IDR stand for in billing?” let’s shift our attention to the challenges you’ll encounter during the independent dispute resolution process.
The first challenge you’ll encounter is cost. There is an administrative fee of $115 per party. The third-party arbitrator also charges a fee, which ranges from $200-$1,173. However, the fee schedules can be adjusted from year to year.
Not only will it cost you hundreds of dollars to initiate an IDR claim, but it can also take months for the insurer to pay you the additional money they owe. That’s if the arbitrator rules in your favor.
Improving payer negotiations and promoting pricing transparency with patients is important. If you have favorable contract terms with payers and a clear understanding of what is and isn’t covered, your organization can reduce revenue loss and minimize the need for costly IDR claims.
Solutions providers like Rivet Health offer the tools you need to promote transparency and optimize your revenue cycle. Rivet Health can help you collect on patient pricing estimates. To learn more, browse our free webinar webinar library and eBook library for content.
Rivet Health is a comprehensive revenue cycle management solution for healthcare organizations. Our patient cost estimate software promotes transparency and compliance with the No Surprises Act.
Rivet Health can streamline No Surprises Act dispute resolution via our payer performance and reimbursement trend monitoring capabilities. Use our platform to quickly identify discrepancies in contract terms and streamline the IDR submission process.
If you have to initiate an independent dispute resolution, our platform helps you build a strong argument for additional reimbursement.
Independent dispute resolution plays a vital role in medical billing by providing a structured process for resolving payment disputes. By leveraging technology like Rivet Health, your organization can streamline the IDR process and reduce revenue leakage.
Ready to optimize revenue? Schedule a demo with Rivet Health.
