Medical Revenue Recovery - State Specific IDR Arbitration

Navigating the complexities of medical revenue recovery often involves addressing disputes between healthcare providers
and insurers over out-of-network (OON) claims. The federal No Surprises Act (NSA) provides a framework for Independent
Dispute Resolution (IDR), but many states have implemented their own IDR arbitration processes. Understanding these
state-specific laws is critical for ensuring compliance and achieving fair reimbursement.

The Role of State-Specific IDR Arbitration

State IDR processes provide tailored approaches to resolving disputes over OON claims. While the federal NSA outlines a
general framework, state laws often include unique provisions for determining reimbursement rates, arbitration timelines,
and negotiation requirements. These laws directly impact emergency services, non-emergency ancillary services, and other
healthcare scenarios where disputes commonly arise.

State Variations in IDR Arbitration

Each state’s IDR process has distinctive elements that influence how disputes are resolved:

• Alaska NSA: Requires adherence to the NSA guidelines, with state-specific benchmarks for resolving disputes.
• California NSA: Utilizes state arbitration processes with established criteria for determining "reasonable" reimbursement rates.
• Colorado NSA: Implements timelines and guidelines for arbitration, focusing on ensuring fair compensation for OON providers.
• Connecticut NSA: Emphasizes negotiation and arbitration for disputed claims, relying on UCR rates and other state-defined factors.
• Delaware NSA: Enforces strict arbitration guidelines to resolve disputes for OON emergency and ancillary services.
• Florida NSA: Uses an arbitration system that incorporates state databases to define fair market reimbursement rates.
• Georgia NSA: Implements a balance billing law with arbitration options for unresolved disputes between insurers and providers.
• Illinois NSA: Requires insurers and providers to follow state-specific benchmarks during dispute resolution.
• Maine NSA: Offers arbitration based on state-defined reimbursement standards for OON services.
• Maryland NSA: Includes detailed negotiation and arbitration processes with state-specific rate determination criteria.
• Michigan NSA: Relies on UCR benchmarks and arbitration to resolve disputes related to emergency and ancillary services.
• Missouri NSA: Focuses on arbitration for disputes, using state-defined criteria for determining fair payment rates.
• Nebraska NSA: Enforces negotiation and arbitration processes under state-specific NSA guidelines.
• Nevada NSA: Adopts strict timelines and arbitration criteria to ensure resolution of payment disputes.
• New Hampshire NSA: Uses benchmarks like the median contracted rate for arbitration outcomes.
• New Jersey NSA: Requires arbitration with consideration of several factors, including UCR and regional benchmarks.
• New Mexico NSA: Implements a structured arbitration process to resolve disputes for OON claims.
• New York NSA: Employs a robust IDR process where arbitration focuses on the 80th percentile of charges from a benchmark database.
• Ohio NSA: Relies on state-specific processes to determine reimbursement through negotiation and arbitration.
• Pennsylvania NSA: Implements arbitration processes based on state-specific benchmarks and timelines.
• Texas NSA: Requires arbitration for OON provider disputes, using benchmarks like the 80th percentile of charge data.
• Virginia NSA: Emphasizes "commercially reasonable" rates, with a defined 30-day negotiation period before arbitration.
• Washington NSA: Includes provisions for consulting the APCD and determining reimbursement based on multiple factors.

Why State-Specific Knowledge Matters

The nuances in each state’s IDR arbitration laws impact how medical revenue recovery is pursued. For instance:

• Texas: Arbitrators consider data benchmarks like the 80th percentile of charges.
• Virginia: Mandates a 30-day negotiation period and emphasizes "commercially reasonable" rates.
• Washington: Allows parties to consult the All-Payer Claims Database (APCD) during arbitration.

Understanding these distinctions is essential for effective dispute resolution and securing equitable reimbursement.
Tailored strategies ensure compliance with both federal and state laws, helping healthcare providers recover lost
revenue while avoiding costly penalties.

Partnering for Success in Revenue Recovery

With the complexities of state-specific IDR arbitration, having expert guidance is crucial. Whether managing federal NSA
processes or navigating state-specific regulations, partnering with a knowledgeable medical revenue recovery team ensures
compliance, maximizes reimbursements, and streamlines the dispute resolution process.