ASCs and anesthesia groups that use the federal independent dispute resolution process to challenge out-of-network underpayments are about to see a significant reduction in the cost of doing so.
HHS, CMS, the Labor Department and the Treasury Department finalized a rule May 28 overhauling the federal IDR process under the No Surprises Act.
Here are six things to know:
- The administrative fee per party per dispute will drop from $115 to $15, a reduction of more than 85%. The change directly affects the economics of disputing smaller claims, an issue that has frustrated specialty practices since the IDR process launched in April 2022. For anesthesia groups in particular, where individual claim values are far lower than surgical claims but volume is high, the lower fee makes it cost-effective to challenge a wider range of underpayments.
- The IDR system has been overwhelmed since launch. It has received more than 5 million disputes, far exceeding federal expectations and creating significant backlogs. “This rule cuts through bureaucratic delays, strengthens transparency between payers and providers, while continuing to protect patients from unnecessary financial stress,” HHS Secretary Robert F. Kennedy Jr. said in a statement. CMS Administrator Mehmet Oz, MD, said the rule is “about making government processes efficient, accountable and focused on results.”
Industry stakeholders also welcomed the changes. James Bobeck, CEO of Federal Hearings & Appeals Services, a certified IDR entity and national leader in medical review and dispute resolution, said the updated rules “will deliver a better, smarter and more efficient IDR process.” He pointed to enhanced regulations governing open negotiations, batching, and information exchange between parties as changes that “will clarify the process and reduce the number of ineligible filings that enter the process today.”
- The IDR process has become both a critical reimbursement tool and a persistent source of frustration for anesthesia and ASC leaders. Anesthesia has been one of the specialties most affected by surprise billing protections, given how frequently anesthesiologists deliver services at in-network facilities under out-of-network contracts.
Antonio Hernandez Conte, MD, former president of the California Society of Anesthesiologists, previously told Becker’s, “the No Surprises Act remains a continual burden for anesthesia practices as insurers delay payments for up to 90 or 120 days even if anesthesia groups are successful in the arbitration dispute resolution process.”
Providers are winning the majority of arbitrations, at around 80% of IDR determinations in 2023, according to HHS data.
- The rule expands batching flexibility, allowing more claims to be resolved together in a single dispute while placing reasonable limits on the number of claims per batch: The change responds to a major pain point for high-volume specialty practices. Fort Worth-based Radiology Associates of North Texas recently projected more than $51 million in avoidable administrative costs tied to current batching rules and unpaid IDR awards, saying federal interpretations were forcing providers to split similar claims into thousands of smaller arbitration filings with separate fees.
The batching question is particularly relevant for anesthesia groups and ASCs, which generate high volumes of repetitive, similar-CPT claims that under current rules can be difficult to consolidate.
- Payers will be required to use standardized claim codes when communicating about out-of-network services, helping providers determine earlier whether a claim qualifies for IDR: A new centralized IDR gateway platform will also launch in phases beginning in 2026, allowing users to start disputes, track status and manage activity in one place. The gateway will eventually require payers to register, making it easier for providers to identify the correct party and reduce errors.
- Enforcement gaps remain a concern: A recent court ruling found providers do not have a private right of action under the No Surprises Act to enforce unpaid IDR awards, meaning a favorable arbitration decision does not always translate to payment. The new rule does not address that gap.
In July, the American Society of Anesthesiologists joined the American College of Radiology and American College of Emergency Physicians in supporting the No Surprises Enforcement Act, which would impose a penalty three times the difference between the insurer’s initial payment and the IDR arbiter’s ruling per claim.”Insurance companies taking advantage of flaws in the NSA system jeopardizes the sustainability of anesthesia practices, threatening access to care,” Donald Arnold, MD, who at the time was serving as ASA president, told Becker’s.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.