CMS Provides Update on Federal Independent Dispute Resolution Process

The CMS has released the latest update regarding the federal Independent Dispute Resolution (IDR) portal.

Established just over one year ago on April 15, 2022, the portal allows providers, facilities, group health plans, health insurance issuers, and Federal Employee Health Benefits Program carriers to determine the appropriate out-of-network payment rate for items and services subject to the surprise billing protections in the No Surprises Act through an IDR process.

CMS reported 334,828 disputes initiated through the portal between April 15, 2022, and March 31, 2023, which is 14 times higher than the originally projected number. Non-initiating parties challenged the eligibility of 122,781 (or just over one-third) of these disputes, and of the disputes closed during this period, 39,890 (or just under one-third of those challenged) were ultimately deemed ineligible for the federal IDR process.

Overall, certified IDR entities closed 106,615 disputes as of March 31, 2023, and rendered payment determinations in 42,158 of these disputes, with the initiating parties prevailing approximately 71% of the time. Certified IDR entities also closed disputes for reasons other than ineligibility or payment determinations, such as cases where the parties reached their own settlements or had unpaid fees.

CMS observed that dispute eligibility issues are the primary cause of delays thus far and is looking at ways to streamline that process going forward. CMS is considering adding data elements to the dispute initiation form to ensure it includes information sufficient to identify the item or service under dispute and the disputing parties and directing parties to attach documents supporting or contesting eligibility to ensure that certified IDR entities have all required information to make eligibility determinations more efficiently.

Federal IDR Process: CMS Status Update »