Coverage note
IDR Costs Nobody Budgeted For: 3 Problems Payers Keep Hitting
Read the original at Fierce Healthcare
Read “IDR Costs Nobody Budgeted For: 3 Problems Payers Keep Hitting” at Fierce Healthcare →Machine-written summary. The paragraph and the list below were written by a language model reading Fierce Healthcare's article, not by The 5:45's editors, and they describe that article rather than add to it. (model: @cf/ibm-granite/granite-4.0-h-micro) The original, linked above, is the actual reporting.
This article from Fierce Healthcare explores the challenges faced by health plans and TPAs in handling out-of-network (OON) claims under the No Surprises Act, highlighting three key issues that are proving difficult to resolve on their own. The piece emphasizes the need for a strategic, pricing-first approach to OON claims to mitigate financial risks and improve outcomes.
What Fierce Healthcare reported
- The claim handling process for OON claims often involves multiple teams working in silos, leading to incomplete and inconsistent processing of claims.
- Ancillary billing practices, such as overcharging for assistant surgeons, remote neuromonitoring services, and high-acuity ER codes, have become problematic as they are not adequately challenged in dispute resolutions.
- Winning arbitration is not the primary goal; instead, the focus should be on defensible pricing and negotiation strategies to minimize the need for IDR (Incorrect Disbursal Recovery) and reduce financial losses from OON claims.