Use of the IDR Process to Settle NSA Disputes Is Greater Than Anticipated

Highlights

Below is a summary of the highlights for the period from April 15, 2022-March 31, 2023:

• Disputing parties initiated 334,828 disputes through the federal IDR portal, which is fourteen times as many cases as the Departments initially estimated the caseload would be annually.

• The non-initiating party challenged the eligibility of 122,781 of these disputes. Note that regardless of whether the eligibility of a dispute is challenged, the IDR entity must confirm eligibility before a dispute can start.

• IDR entities closed 106,615 disputes as of March 31,2023, more than four times the volume the Departments initially estimated for a calendar year.

• Reasons disputes are closed include payment determinations, the parties withdrawing a dispute or reaching a settlement outside the IDR process, and unpaid fees.

• Of the disputes closed during this period, 39,890 were determined ineligible – about 37%.

• Payment determinations were made for 42,158 disputes, less than 15% of disputes initiated.
• In disputes where a payment determination was made, IDR entities ruled for the initiating party in approximately 71% of the disputes.

Claritev’s Learnings from the Report

• Non-initiating parties believe that many disputes are not eligible for federal IDR. The number of disputes that non-initiating parties would like to challenge is far more than reported by CMS because in many instances, payers are unable to identify eligibility objections within 3 business days of receipt of the IDR notice.

• Determining eligibility is a time-consuming process for IDR entities and non-initiating parties.

• When an IDR entity makes a payment determination on the merits, it has more often than not been for the party who initiated the dispute. Strategically, it is critical that non-initiating parties quickly identify and assert eligibility objections as a sizable number of disputes are closed based on ineligibility.