Eric W. Christensen, PhD
January 17, 2024 — According to the American Journal of Roentgenology (AJR), the No Surprises Act’s (NSA) independent dispute resolution (IDR) process would be financially unfeasible for a large portion of out-of-network (OON) claims for hospital-based specialties — more so for radiologists than other specialists.
“Although the NSA enacted important patient protections, IDR fees limit clinicians’ opportunities to dispute payer-determined payments and potentially undermine their bargaining power in contract negotiations,” wrote AJR first author Eric W. Christensen, PhD, of the Neiman Health Policy Institute in Reston, VA. “Therefore, IDR rulemaking may negatively impact patient access to in-network care.”
Christensen et al.’s accepted manuscript extracted claims from Optum’s de-identified Clinformatics Data Mart Database for hospital-based specialties occurring the same day as in-network emergency visits or inpatient stays (January 2017–December 2021). After identifying OON claims, claims were then batched via simulated IDR rules. Maximum potential recovered payments from the IDR process was estimated as the difference between charges and allowed amount. The percentage of claims for which the maximum potential payment, and one-quarter of this amount — a more realistic payment recovery estimate — would exceed IDR fees was determined, using $150 and $450 fee thresholds to approximate the range of final 2024 IDR fees. These values represented the percentage of OON claims that would be financially viable candidates for IDR submission.
Ultimately, the percentage of radiologists’ OON claims for which the maximum potential recovered payment exceeded fee thresholds of $150 and $450 (i.e., financial breakeven points for entering the NSA IDR process) was 55.0% and 32.1%, respectively; at payment of one-quarter of the maximum amount, these percentages were 26.9% and 10.6%, respectively.
Dr. Christensen discusses his research that assesses the fraction of out-of-network claims for which radiologists and other hospital-based specialists can expect to at least break even when challenging payer-determined payments through the No Surprises Act independent dispute resolution process, as a measure of the process's financial viability.
For more information: www.arrs.org
July 24, 2024 
