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 examines the challenges faced by health plans and TPAs in managing 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 management to mitigate financial risks and improve outcomes.
What Fierce Healthcare reported
- The claim handling process for OON claims often involves multiple departments without end-to-end coordination, leading to fragmented claim resolution and potential billing gaps.
- Ancillary billing practices, such as overcharging for assistant surgeons, remote neuromonitoring services, and high-acuity ER codes, are no longer defensible and can result in significant billing discrepancies that are difficult to resolve.
- Winning arbitration is not the primary goal; instead, the focus should be on defensible pricing and negotiation strategies that minimize the need for arbitration and reduce the financial impact of OON claims.