The No Surprises Act (NSA) requires that the Departments of Health and Human Services (HHS), Labor, and the Treasury (collectively, the Departments) publish certain information relating to the Federal Independent Dispute Resolution (IDR) process every calendar quarter as of 2022.
As part of this requirement, on December 27, the Departments released the Initial Report on the Independent Dispute Resolution (IDR) Process stating, “Because this first report requires substantial manual processing by both certified IDR entities and the Departments, the Departments are limiting the scope of this report to a partial report of the first and second calendar quarters (2022 Q2 and 2022 Q3).”
Notably, the Departments aim to automate “to the extent feasible all aspects of the Federal IDR process.” However, the Federal IDR portal (launched April 15, 2022) presently requires a lot of human-touch time to sufficiently process dispute data, which is causing delays.
The report cites that from April 15 – September 30, 2022, a total of 90,078 disputes were initiated via the Federal IDR portal. This is significantly more than the Departments initially anticipated for a 12 month period. While 23,107 of these disputes have been closed, only 15% of the closed disputes achieved a payment determination; 69% of the closed disputes were deemed ineligible for the Federal IDR process. In fact, of the more than 19,000 cases Claritev received through Q3 2022, 68% were determined to be ineligible. Our team spends on average over 20 minutes to determine a case’s eligibility for the IDR process. This timeframe can increase if information is requested by multiple parties.
The majority of disputes initiated that are referenced in the report pertain to out-of-network (OON) emergency and non-emergency services. The top ten representatives for these disputes initiated 75% of them. The top party, SCP Health, is estimated to have filed roughly a third of all OON emergency and non-emergency disputes.
Over 600 unique non-initiating parties submitted to the Federal IDR portal during the period. These non-initiating parties challenged Federal IDR process eligibility in 40,517 disputes pertaining to OON emergency or non-emergency services, which is nearly half of the total number of disputes submitted during the two quarters. 11,030 of these disputes were closed as of September 30, 2022 with 80% being ultimately deemed ineligible for the Federal IDR process.
The report further highlights that Claritev submitted 9,296 disputes to the Federal IDR portal as a non-initiating party over 2022 Q2 and 2022 Q3. This placed Claritev in the top three most active non-initiating parties and represents 11% of all disputes involving emergency and non-emergency items.
The release of this data sheds more light on the complexities of the No Surprises Act and its associated obstacles. Notably, this is a “partial report” because pulling and cleaning the data for the full report is simply taking too much time. A full report will be released in the future, however, the partial report does not advise when this will be. In order for the Departments to provide the data which they are legally obliged to release per the NSA, process improvements and system developments must continue to take shape.
