IDR Cottage Industry

[cittykat]

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Unintended consequences of NSA.

There was an orthopedist on Doximity who was taking every case to IDR and encouraging others to follow suit. One way to fight back.

A $440,000 Breast Reduction: How Doctors Cashed In on the No Surprises Act and Arbitration

A law meant to end surprise medical billing accidentally created a multibillion-dollar industry that is making doctors richer.

www.nytimes.com

 

[chessknt]

The author of this article writes like a shill for the insurance company. Maybe if the insurance company negotiated an in-network rate that wasn't an insult and in alignment with normal it would have gotten much better deal but we don't see that take at all.

 

[cittykat]

https://www.beckersasc.com/anesthesia/no-surprises-act-arbitration-7-stats-asc-leaders-should-know/

 

[CopaceticOne]

https://www.beckersasc.com/anesthesia/no-surprises-act-arbitration-7-stats-asc-leaders-should-know/

Not surprised to see that PE is a big percentage of IDR cases

 

[cchoukal]

I have a close friend who is an attorney on the insurance regulatory side, and he echoed that a lot of anesthesia groups are doing very well in IDR.

 

[UscGhost]

So, is this for anesthesia groups that are OON and working at In network facilities?

 

[Shimmy8]

NYT also wrote all the NSA propaganda with insurance companies (esp United) in their back pocket.

No surprise. It’s the only card they have left at the moment now that they wrote a stupid bill.

 

[DesiredMemberName?]

Are the PE AMC’s back in business then?

 

[sloh]

Doctors and PE team up to dominate insurers. Love it haha

 

[Southpaw]

Doctors and PE team up to dominate insurers. Love it haha

Your run of the mill doctor likely isn’t able to take advantage of IDR in the way PE and celebrity doctors are. For ‘reasons’.

 

[sloh]

The author of this article writes like a shill for the insurance company. Maybe if the insurance company negotiated an in-network rate that wasn't an insult and in alignment with normal it would have gotten much better deal but we don't see that take at all.

Agreed. I’m rooting for Dr. Rowe.

“Michael Gottlieb, the lawyer who handles Dr. Rowe’s arbitration filings, declined to speak about continuing litigation but did broadly defend his clients’ seeking much higher amounts than insurers typically pay. He described the arbitrators as having “reverse sticker shock” at how low the health plan payments were.

“When they got wind of three-digit payments for massive, complex surgeries and they know they pay their plumber more to fix a toilet, they just gravitate toward the providers’ offers even if they do seem eyebrow-raisingly high,” he said.”

 

[sloh]

Your run of the mill doctor likely isn’t able to take advantage of IDR in the way PE and celebrity doctors are. For ‘reasons’.

Yup.

“The money does not always end up with the doctors but instead can go to the owners of their practices. The Times interviewed two physicians who show up repeatedly in public data files. Both said they were salaried workers and uninvolved in the claims filed under their names.”

 

[coffeebythelake]

Doctors and PE team up to dominate insurers. Love it haha

Money's not going in the doc's pocket

 

[cittykat]

Money's not going in the doc's pocket

Depends on whether or not they own the practice.

 

[Arch Guillotti]

Money's not going in the doc's pocket

It is if you are an owner of the practice.

 

[urge]

The story doesn’t make sense to me.

Plus it’s the NY Times, sometimes fondly referred as the Toilet Paper of Record

 

[Status Sciaticus]

Hmm, I wonder how this can work out for pain injections that keep getting denied by insurers on stupid reasons.

 

[cittykat]

Hmm, I wonder how this can work out for pain injections that keep getting denied by insurers on stupid reasons.

From the article.

“A New Jersey anesthesiologist was awarded $14,560 in 2025 for an X-ray-guided steroid injection.“

 

[Status Sciaticus]

From the article.

“A New Jersey anesthesiologist was awarded $14,560 in 2025 for an X-ray-guided steroid injection.“

I read that. But it doesnt specify the reasoning as to why it went to IDR. Was it an out of network injection, an in-network denial, or some other reason?

 

[Arch Guillotti]

I read that. But it doesnt specify the reasoning as to why it went to IDR. Was it an out of network injection, an in-network denial, or some other reason?

Does anything ither than an OON denial ever go to IDR?

 

[amyl]

Insurance companies will fix this in their favor… I don’t think this current system will last.

 

[Status Sciaticus]

Does anything ither than an OON denial ever go to IDR?

I have heard (but not seen myself) clawbacks, no-auth required scenarios where insurances refuse to pay, and approved injections that get denied when it comes time to collect.

 

[Arch Guillotti]

I have heard (but not seen myself) clawbacks, no-auth required scenarios where insurances refuse to pay, and approved injections that get denied when it comes time to collect.

I thought that is why pre-approval exists and was just a direct fight with the insurance company if there is a denial.

 

[Status Sciaticus]

I thought that is why pre-approval exists and was just a direct fight with the insurance company if there is a denial.

There isnt such a thing as pre-approval as far as I understand it. Its technically prior authorization, but every prior auth I have seen explicitly states that prior auth is not a guarantee of payment.

 

[cittykat]

Insurance companies will fix this in their favor… I don’t think this current system will last.

NSA with IDR was supposed to be the fix. Maybe they’ll just drop the IDR now.

I wonder how one becomes a selected mediator. Seems like a very good business. Batch processing disputes with AI can be very lucrative with little effort.

 

[amyl]

NSA with IDR was supposed to be the fix. Maybe they’ll just drop the IDR now.

I wonder how one becomes a selected mediator. Seems like a very good business. Batch processing disputes with AI can be very lucrative with little effort.

Eligibility & Certification Requirements​

To become an arbitrator, you must meet federal requirements outlined by the Centers for Medicare & Medicaid Services (CMS), the Department of Labor (DOL), and the Department of The Treasury. Key requirements include:

• Professional Background: Experience in health law, medical coding/auditing, compliance, or dispute resolution. Coders with auditing and compliance credentials (CPC, COC, CIC, CPMA, or CCS) have a strong advantage.
• Independence: You must not have financial ties to health plans or providers you might review.
• Certification Process: Apply to CMS during open application windows to be listed as a Certified IDR Entity.

Application Process​

1. Check CMS Notices: Applications are announced periodically on the CMS No Surprises Act Website.
2. Prepare Documentation: Demonstrate your organization or team’s expertise in medical coding, auditing, and dispute resolution.
3. Conflict of Interest Attestation: Provide safeguards that ensure impartiality.
4. Training: Arbitrators must complete federal training on the No Surprises Act and IDR procedures.