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A lot of medical practices have submitted through the IDR process, or gone through the 30 day negotiation, then gone through the IDR process,

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and ultimately to win. I think over 80% of the time providers win as part of the dispute resolution, only to not receive any payment.

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Welcome to Off the Chart, a Business of Medicine podcast, featuring lively and informative conversations with healthcare experts, opinion leaders, and practicing physicians about the challenges facing doctors and medical practices. My name is Alison Luttrell. I'm the associate editor of Medical Economics, and I'd like to thank you for joining us today.

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In today's episode, Physicians Practice Managing Editor Keith Reynolds sat down with Anders Gilberg, Senior Vice President of Government Affairs at MGMA, to talk about the new independent dispute resolution rule under the No Surprises Act. Keith and Anders break down what the rule actually changes for practices, starting with the steep drop in the fee to initiate a dispute. They also dig into one of the most frustrating problems with the process: physicians who win an arbitration and still don't get paid, and they look at what practices should be watching for next on the regulatory horizon. Anders, thank you, as always, for joining us. With that, let's get into the episode,

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you

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Hey there, folks. Today we're talking to Otters Gilbert, Senior Vice President of Government Affairs for MGMA. How you doing, Honors? Great, Keith. How are you? Not too bad, sweating out here in the woods.

Unknown Speaker 1:57
So today we are talking about the new IDR rules. Why don't you give me a quick rundown of what what's come out of what's come out of the regulatory space on that? Right. Well, as you know, medical practices are they face a lot of different hurdles in a variety of different settings with different payers.

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Just to kind of recap, although I think many of your listeners would would already know much of this is that the IDR rule, the dispute resolution rule, came out of the No Surprises Act, which was, I think, important legislation and a regulatory scheme that set up a process for

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situations, and where, like, a patient would go to a hospital, maybe the hospital was in network, but the physician was out of network, and then disputes would arise about how much to pay the physician. Obviously, you don't want to

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create a situation in which the patient is in the middle and is getting fleeced, and so it's an important legislation, but it is also important

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on the heels of even the Affordable Care Act, where a number of insurers had made their

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provider panels so small, and so a lot of our members were kind of forced out of networks as networks got smaller, and so you have situations with certain specialties like emergency medicine, radiology,

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pathology, certain special anesthesia,

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where you have these situations where you have out of network physicians and in network hospitals, and so we're just trying to make the process as streamlined as possible.

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There are

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lots of situations in the news. I don't think they're the majority where there have been abuses of the process, but that's not what MGMA is all about. We just want to create a fair, equitable process for physicians and medical practices, taking care of patients and in settings like this, so they get paid a fair and reasonable amount. Alright, so y'all have been sort of, you know, pushing for action on this for a couple of

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years, you know. Does the final version that's come out, you know, is that really given us what, you know, medical groups have been asking for? It takes a couple of basic steps that I think are very important, and it reduces

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the, the, the threshold for entry in order to go through the dispute resolution process. I mean, now the administrative fee to initiate a dispute used to be $115

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and now it's $15

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and that is a significant reduction, and for smaller practices that is a huge improvement, and something that we advocated for

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as part of this rule, it also provides a little bit of clarity in terms of which claims are

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subject to the No Surprises Act, so if

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a physician or a practice submits a claim and gets a denial

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or reduced payment on the back end there.

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Would be a remittance advice or code associated with that claim that they would then get from the payer that would indicate this is a claim that is subject to the No Surprises Act, and therefore they could then avail themselves of the process going forward.

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So, like I said, this has been, you know, in the works, sort of under regulatory review for, you know, more than two years. What did that delay cost practices in, you know, the meantime?

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Well, it certainly cost them money

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with the fees at $115

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and then reduced down to 15. That's a significant reduction, and so those delays, you know they just didn't address those transparency issues that I,

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that I talked about, so there was ambiguity created. There were situations, not only just the fees were exorbitant, but that,

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you know,

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claims were submitted that were not eligible for the dispute resolution process, and so

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that confusion and some of that ambiguity and transparency has now been alleviated, so that's positive.

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So, you know, a lot of the

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provisions in this rule are sort of framed as, you know, providing relief for regulatory burden, and you know, all that. You know, where's the administrative burden really sitting still sitting for groups in this sort of process.

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Well, this is, you know, it contributed certainly the trend, you know, the fact that

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now there's going to be more transparency with these CARC and RARC codes, they're called, that will then transmit information back to the providers

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to reflect their eligibility for the process. There still is additional burden on the back end, to

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you know, the process itself is cumbersome. There is a portal to submit information to. There can be additional reforms that

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are still out there to help streamline and reform

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the submission process, and also, kind of, you know, one of the big burdens were that a lot of medical practices

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have submitted through the IDR process, or gone through the 30 day negotiation, then gone through the IDR process,

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and ultimately to win, I think over 80% of the time providers win as part of the dispute resolution, only to not receive any payment. So one of the things hanging out there is actually part of some legislation dealing with the no surprises enforcement aspects of of what we're dealing with here, that you know providers, medical practices, doctors going through the process, winning,

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or at least having their,

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their

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suggested payment, and the dispute resolution upheld by by the arbitration entities, and then only to not receive any payment, because the payers just don't even pay up, even though the provider won in that situation, so

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I think on the back end those are two that jump to mind is a streamlined dispute resolution portal as well as more accountability on the back end in terms of making sure that in situations where a provider or medical practice or doctor has

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has prevailed in the IDR process that they get paid in a prime in a timely manner, so speaking of payers, they're saying that this rule is not doing enough to stop ineligible claims.

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You know, what's MGM A's view on that?

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Yeah, I feel like, you know, I see the same articles that you do, Keith, where you have a few kind of outrageous situations, and where you have, like, you know, one physician in Florida who submits a claim for hundreds of 1000s of dollars and prevails, and you know

Unknown Speaker 8:54
that's not where MGMA is on this. We are simply looking for,

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you know, a fair, equitable process. I don't think that the payers, if they're just kind of hiding behind these more egregious cases, I don't think they're really addressing the main issue, which is the fact that still that providers prevail the vast majority of the time, and I think they could do more to

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step up in the in the IDR process, and

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you know, propose on their end payments that are closer to what an in-network payment is, is for their in-network providers as well, so

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you know, we would beg to differ in some of these situations, but

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again, I think they often highlight the most egregious examples. There's also, you know, many situations that kind of fall outside of our own purview, which is you have a few cases of ownership of

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health systems and entities and practices now.

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Now that are motivated more by profit, and so, but I think those are

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the, those are the exception to the rule. So I think this is an improvement, and we're going to continue to see improvements. This process kind of goes along, hopefully with passage of legislation to enforce the the

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timeliness of payment on the on the provider side or on the pay on the payer side, but

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all in all, I think you know MGMA kind of lays, we're kind of lie in the middle here somewhere, where we're just trying to do what's right for practices that oftentimes are pushed out of network or provided no opportunity to really have a fair contract with an insurer, and then they're forced to be as part of this process to get paid if they, if they are treating an in-network patient.

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Hey there, Keith Reynolds here. And welcome to the p2 Management Minute. In just 60 seconds, we deliver proven, real-world tactics you can plug into your practice today, whether that means speeding up check-in, lifting staff morale, or nudging patient satisfaction north. No theory, no fluff, just the kind of guidance that fits between appointments and moves the needle before lunch. But the best ideas don't all come from our newsroom. They come from you. Got a clever workflow hack, an employee engagement win, or a lesson learned the hard way? I want a feature. Shoot me an email at K reynolds@mjlifesciences.com

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So, you know, for an administrator who's just, you know, reading this news,

Unknown Speaker 11:56
I think the biggest change is probably, you know, the fee reduction down to, you know, 15 bucks. You know what, besides that, though, do you think would be the, the biggest thing that actually affects their day-to-day operations?

Unknown Speaker 12:07
Well, again, I don't think this necessarily affects the majority of administrators, too, like you're dealing with mostly some of these specialties that I mentioned, emergency medicine, anesthesia, radiology, you know, where you're not necessarily, in some cases, you're seeing the patients, sometimes you're not, but you're contracted to, you know, provide care in a hospital, and maybe in certain situations out of network, and so for a typical administrator, I don't necessarily think they've availed they're going to avail themselves of the IDR process as a common situation, but for those specialties, administrators in those specialties,

Unknown Speaker 12:41
you know, I still think, as you mentioned, I mean, the process still is frustrating. It's now

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less costly.

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They should pay attention to the opportunity now that it, they've reduced the fees, and the fact that now they're going to provide that the insurers are going to provide a little bit more clarity, and so for administrators to just when you get those remittance advice

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notices back on claims is now you can more realistically consider

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appealing

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a denial or whatnot because you know which claims are affected the process is relatively clear

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there's a 30 day

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open negotiation process where you can reach out to the payer and hopefully agree on some payment, but if not, then go through this IDR process and get paid for the care you're delivering, so as long as it's, you know, fair and reasonable

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proposal

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in the arbitration

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that the baseball style arbitration process that IDR provides, I think the IDR arbiters often rule in favor of the of the provider, so an administrator should, should consider carefully, but know that they have recourse now when these claims are denied. Okay, now comes my favorite part of all interviews with you, honors. I want you to get in the head of the administration, you know.

Unknown Speaker 14:08
Does this rule, you know, is this a sign of a broader shift on how it's approaching the No Surprises Act? And you know, what should practices watch for next?

Unknown Speaker 14:18
Well, I don't necessarily think this is like a harbinger of things to come on different issues. I there are a number of issues out there completely unrelated to this, but we do appreciate the fact that they've looked at and are continuing to think about the providers and these processes, and so

Unknown Speaker 14:38
you know, hopefully with a little help on the legislative side, on the enforcement side, that there can be some support for those providers that have won arbitration and just aren't getting paid.

Unknown Speaker 14:50
I think, like setting this aside, there are a number of rules that I would say to your audience and MGMA members in general, you know, we have.

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Multiple two HIPAA rules that are pending out there, one dealing with privacy, one dealing with security, that may come out, and in the coming months, the physician fee schedule will come out here in the next, let's say, the beginning of July, 30 days, so we're going to see a lot of things impacting payment,

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and those will be some major

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potential milestones on the regulatory process for the rest of the year as we get up toward the election. Then, after the election, there's a lot of unresolved issues that need to be resolved before 2027

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so there'll be a lame duck session, hopefully

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to pass different things, like, you know, we're back to dealing with things like geographic price indices, different kinds of

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payment issues that expire at the end of this year that will be important to

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typical administrators, physicians, MGMA members. So

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you know it's going to be a busy summer,

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and

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stay tuned till after the election, but we're very pleased with what happened here in this rule. I think it's a great start in moving this process to a little bit more equitable, fair, less costly, less burdensome. So, we'll take it as a win and move on from there. Alrighty, Anders, that's all I got for you. Anything else you want to add? No, thanks. It's great to see you, Keith, and it's always a pleasure, and I will be bugging you on all those other things, so be prepared. All right. Thank you so much

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once again. That was Anders Gilberg, Senior Vice President of Government Affairs at MGMA, speaking with Physicians Practice Managing Editor Keith Reynolds on behalf of the whole medical economics and physicians practice teams. I'd like to thank you for listening to the show, and SD, please subscribe, so you don't miss the next episode. As always, be sure to check back on Monday and Thursday mornings for the latest conversations with experts sharing strategies, stories, and solutions for your practice. You can find us by searching Off the Chart wherever you get your podcasts. And if you think the best stories that Medical Economics and Physicians Practice publish, delivered straight to your email six days of the week, subscribe to our newsletters@medicaleconomics.com

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and physicianspractice.com

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Off the Chart: A Business and Medicine podcast is executive produced by Chris Mazzolini and Keith Reynolds and produced by Austin Latrell. Medical economics and physicians practice are both members of the MJH Life Sciences family. Thank you.

Transcribed by https://otter.ai