The No Surprises Act (NSA) came into effect in 2022 and aims to protect patients from surprise medical bills in certain scenarios, such as emergency care and out-of-network care provided at in-network facilities. However, the Act is facing payer-side legal challenges due to insurers frequently refusing to reimburse providers for care delivered under such circumstances.
Against this backdrop, internal dispute resolution (IDR) has emerged as a viable and often successful way for hospitals and health systems to reclaim previously denied payment.
During a November Becker’s Hospital Review podcast sponsored by HaloMD, Patrick Velliky, chief external affairs officer at HaloMD, discussed emerging IDR trends, how revenue cycle leaders should view IDR through the prism of forthcoming legislative changes, and what arbitration outcomes signal for payers and providers moving forward.
Three key insights were:
- Trends from early IDR cases are positive for providers and facilities. Data from the CMS Health Insurance Exchange Public Use Files, which include details about outcomes of IDR arbitration, show an 80% or higher success rate for providers involved in such disputes. “When providers engage in arbitration, they usually win and are able to obtain fair and sustainable rates,” Mr. Velliky said. “So if you are concerned about out-of-network reimbursement [for cases that fall under the NSA], the IDR process might be a solution worth considering.”
- Forthcoming legislative changes likely mean more revenue challenges for providers. Changes going into effect in 2026 that will likely increase levels of uncompensated care include the One Big Beautiful Bill Act (OBBBA), the potential sunset of insurance exchange subsidies and increasing rates of an unfavorable payer mix. “Being aware of those changes will hopefully allow leaders to look into the potential impact on their facilities and identify gaps. IDR is one way they may be able to close those gaps,” Mr. Velliky said.
- In light of these revenue challenges, providers should use IDR as a means to a bigger end. While arbitration can be useful in resolving unreimbursed care that falls within the scope of the NSA, it can also aid healthcare facilities in achieving longer-term goals, such as securing sustainable in-network contractual arrangements with payers. In fact, that was the original idea behind the NSA and its arbitration component.
“The idea is that a payer and a provider might go through an arbitration process for several rounds and that process ought to help them understand where the economic equilibrium is,” Mr. Velliky said. He noted that the IDR process is intentionally designed to be cumbersome and expensive, to discourage both parties — especially payers — from relying on it as a long-term solution.
“If [payers] want to address some of the unnecessary costs embedded in the system, the answer is to get in network at the rates that have been prevailing in the IDR process.”
