120.887 Advocating for a Prompt and Fair Federal IDR Process for Out-of-Network Disputes
MSSNY will advocate, and ask the AMA to advocate for, a prompt and fair federal IDR process that includes:
(1) timely processing of claims;
(2) directions to the IDR entity that no one data point is deemed in advance to be more important than any other consideration;
(3) direction to insurers only to use actual paid rates in consideration of the median contracted rate;
(4) directions to insurers not to consider data from other specialties in determining the median contracted rate;
(5) direction to insurers not to consider data from other self-funded plans in determining the median contracted rate;
(6) direction to insurers that they must present the median contracted rate to the physician in the EOB if they want to use this data point at IDR;
(7) direction to insurers to make all raw data available to the disputing physician from which the median contracted rate was calculated so the physician can ascertain whether the median contracted rate was calculated correctly;
(8) eliminating the non-refundable administrative fees for physicians to bring a claim to IDR;
(9) allowing physicians to batch similar claims;
(10) providing live help for phone calls from both federal regulating departments and the IDR entities to facilitate the timely processing of claims;
(11) requiring insurers to make payments within 30 days when they lose at IDR (as per the law). (HOD 2023-52)
