Across The Country IDR Filings Have Skyrocketed.
“Under Medicare, the procedure reimburses about $1,145. But through arbitration, this practice has routinely secured average awards exceeding $100,000…… The NSA/IDR is a growth business and there is zero incentive for OON providers to fairly contract.”
Aldeen’s Sunday Morning Bathroom Read by Doug Aldeen
Georgetown University’s Center on Health Insurance Reforms found that more than 850,000 disputes were filed in the second half of 2024 – around 100 times the government’s original projection. The volume is only part of the story. Payment requests have grown dramatically too. Providers initiate and win the overwhelming majority of these cases, often at payment levels many multiples higher than the law’s benchmark rate, known as the Qualifying Payment Amount (QPA) – the median in-network rate for the same service.
But another problem is emerging: a large and growing share of disputes should never be in IDR at all.
A recent national survey of health plans conducted by AHIP and the Blue Cross Blue Shield Association found that nearly 40 percent of disputes submitted to IDR in 2024 were identified as ineligible under the rules Congress established. Yet many of these cases still advanced through arbitration instead of being screened out. The health plans operated by Elevance Health see a similar pattern. Certain billing firms submit thousands of disputes at a time – many of which are ineligible – using IDR as a revenue strategy and taking advantage of limited enforcement of eligibility standards. Arbitrators, who are paid only when cases proceed, have an incentive to allow these ineligible disputes to move forward, further distorting outcomes.
A striking example is breast-reduction surgery, which is one of the costliest IDR procedures in the country. One practice in Connecticut is responsible for more than half of all arbitration dollars for this single code in the state – and roughly half of the cases it won were ineligible or out-of-scope to begin with. Under Medicare, the procedure reimburses about $1,145. But through arbitration, this practice has routinely secured average awards exceeding $100,000, making IDR not just a costly workaround but, in many cases, a channel for adjudicating disputes that never should have entered the system. A small number of high-cost specialties – plastic and reconstructive surgery, spine and orthopedic surgery, and neuromonitoring – now account for most IDR dollars nationwide. Many of these procedures are elective and scheduled in advance at in-network hospitals. But the use of out-of-network specialists at in-network hospitals means arbitration becomes a back door to higher payments.”
Sunday Morning Bathroom Read Takeaway ( Price Maker or Price Taker):
Price Maker Strategy: The NSA/IDR is a growth business and there is zero incentive for OON providers to fairly contract. See above details
