Physicians will not see changes in 2025 to federal independent dispute resolution (IDR) fees tied to the No Surprises Act, the Centers for Medicare & Medicaid Services recently announced.
For the coming year, the administrative fee amount will remain $115 per party per dispute. The certified IDR entity fee ranges are $200-$840 for single determinations and $268-$1,173 for batched determinations.
The federal IDR process allows physicians to dispute health plans’ initial payment for certain out-of-network care. An independent arbitrator, certified to settle IDR cases, reviews the specifics of a disputed payment, determining a final amount following input from both the physician and payer.
The $115 fee amount, a nonrefundable fee each party in a dispute must pay, represents a significant reduction from what was once a proposed $350 fee.
TMA litigation successfully challenged a planned administrative fee rate hike from $50 to $350. TMA then filed comments in October 2023 and January 2024, responding to follow-up proposed rules that would have set the fee at $150.
Though the three federal departments overseeing implementation – the Department of Health and Human Services, the Department of Labor, and the Department of the Treasury – have kept the administrative fees and IDR entity fee ranges at the same level for at least this year, some physicians familiar with the IDR process still express concerns about the time and energy costs, as well as the financial costs, associated with the federal IDR process.
“It creates a cash flow problem,” said Christopher Cook, DO, who estimates he’s engaged in about 900 different IDR cases. "You really create a situation where you're having to hold money out that you can't use for your practice or anything else.”
He added that while larger groups are better equipped to deal with these disputes, he’s challenged by being a small, independent practice – estimating he may stay up until midnight on weekdays or spend up to 12 hours on weekends tending to arbitration.
Carrie De Moor, MD, an emergency medicine physician based in Frisco, who had to close a practice in 2020 in part due to issues with insurance payment, agrees the federal IDR system is especially challenging for independent practices. When she was running a practice and engaging health plans in payment disputes, her options were either to seek attorney assistance and pay out legal fees or shoulder the fight herself, she says.
“Small groups cannot survive,” she assessed. “They don't have the resources to continue to fight.”
But it’s a fight she’s still willing to take on, she notes.
“You have to fight for it, because they'll just keep getting away with it,” she said of engaging in the IDR process. “In that regard, yes, it’s worth doing it and going through the process.”
Since 2021, the Texas Medical Association has successfully sued federal regulators multiple times over the implementation of the No Surprises Act’s provisions related to the IDR process between physicians and payers.
For more education on payer issues, sign up for TMA’s continuing medical education programs on these topics. For assistance on payment issues, reach out to the Physician Payment Resource Center.
Phil West
Associate Editor
(512) 370-1394
phil.west[at]texmed[dot]org
Phil West is a writer and editor whose publications include the Los Angeles Times, Seattle Times, Austin American-Statesman, and San Antonio Express-News. He earned a BA in journalism from the University of Washington and an MFA from the University of Texas at Austin’s James A. Michener Center for Writers. He lives in Austin with his wife, children, and a trio of free-spirited dogs.