Under the NO SURPRISES ACT if there is a payment dispute (balance billing) from a provider, the health plan is required to participate in a third-party, unbiased arbitration process to establish a qualifying payment amount (QPA) for similar services in a geographic area.
The Independent Dispute Resolution (IDR) process only comes into play when an agreement isn’t reached through the normal appeal process and a provider decides to risk paying the cost ($200-$500) of going to an independent arbiter.
Independent Dispute Resolutions Are Not Inevitable” Under No Surprises Act
Source: Valenz, 12/10/2021
PHOENIX, AZ — In response to “growing and unnecessary concern” about Independent Dispute Resolution (IDR) requirements that begin Jan. 1, 2022, under the No Surprises Act (NSA), leaders at Vālenz® are reaching out with assurance to clients that they already have proven tools to mitigate and even eliminate the need for IDRs.
Under the NSA, if there is a payment dispute from a provider, the health plan is required to participate in a third-party, unbiased arbitration process to establish a qualifying payment amount (QPA) for similar services in a geographic area. The health plan may need outside resources to fulfill claim settlement support for the IDR process, a stipulation that has created a rush of new IDR support solutions in market.
However, according to Rob Gelb, Valenz Chief Executive Officer, there is no need for Valenz clients to engage with new pop-up IDR solutions. For years, Valenz has used its proprietary VMS™ repricing methodology to circumvent payment disputes by ensuring fair, defensible, market-sensitive QPAs that both parties agree to. QPAs are based on years of real-world data from Valenz Access contracted networks, as well as additional layers of data from the broader Valenz ecosystem. Valenz has always negotiated with providers in the rare instances where they appeal a QPA. The IDR process only comes into play when an agreement isn’t reached through the normal appeal process and a provider decides to risk paying the cost of going to an independent arbiter.
“As a health data tech company with deep roots in member advocacy, our business model is built on a framework of clinical care management with a decades-long commitment to validation, integrity and accuracy (VIA). We’ve been delivering agile, data-driven solutions to pricing and reimbursement for years, always engaging early and often for smarter, better, faster healthcare,” said Gelb. “For us, this is not new at all – our repricing methodology is tried and true.”
Gelb advises all self-insured employers to embrace the power of transparency and data for improving the high costs of healthcare coverage today – and be cautious of solutions that don’t address root causes. “While others are fueling fear that IDRs will now be commonplace, we’re here to say the opposite – IDRs are not inevitable features of NSA compliance, not when you partner with Valenz.”
For more information about VMS™ visit valenzhealth.com/vms. To discuss how Valenz ensures fair and defensible pricing, call (866) 762-4455.
About Valenz
Valenz enables self-insured employers to make better decisions that control costs across the life of a claim while empowering their members to lead strong, vigorous and healthy lives. Valenz offers transparency through data to pinpoint members at highest risk, address gaps in network designs, ensure appropriate and accurate charges, and expertly navigate employees to optimal care solutions for substantial cost savings and improved health outcomes. Visitvalenzhealth.com. Valenz is backed by Great Point Partners.
RiskManagers.us is a specialty company in the benefits market that, while not an insurance company, works directly with health entities, medical providers, and businesses to identify and develop cost effective benefits packages, emphasizing transparency and fairness in direct reimbursement compensation methods.
