The Federal Independent Dispute Resolution (IDR) process, established under the No Surprises Act (NSA), was designed to resolve out-of-network payment disputes between providers and insurers through an independent third-party arbiter in efforts to protect patients from surprise out-of-network medical bills. However, many healthcare providers are finding that insurance companies are creating unnecessary hurdles in this process. One such example is when insurers partake in issuing Explanation of Benefits (EOBs) that do not comply with federal requirements, resulting in a significant obstacle for providers to engage in this process.
What the Law Requires: Key Elements of the EOB
Under the NSA, insurers must include a notice of open negotiation in EOBs to ensure that providers are aware that the claim is eligible for NSA and, therefore, must go through the IDR process. Open negotiation is the first step in the IDR process. It is a prerequisite to initiating the IDR process, making it crucial that the provider initiates open negotiation in a timely manner.
The Problem: Noncompliant EOBs
A noncompliant EOB has a detrimental effect on a provider’s opportunity to seek proper reimbursement for its services. The IDR process is one of the main avenues through which providers can seek reimbursement for most out-of-network claims. The IDR process has strict federal deadlines, and if the provider misses a deadline, this can cause significant delays to a provider’s recourse for a payor’s underpayment. A payor’s nondisclosure of the open negotiation notice timeframe creates a major issue, depriving providers of their right to seek proper reimbursement.
