Independent Dispute Resolution Entity (IDRE)

Introduction

The Department, in accordance with Financial Services Law Article 6 and 23 NYCRR Part 400, established an Independent Dispute Resolution (IDR) process by which a dispute for a bill for emergency services or a surprise bill for health services may be resolved. When such a dispute arises, an Independent Dispute Resolution Entity (IDRE) is tasked with determining whether the provider’s fee or the health plan’s payment is more reasonable.

The Department seeks to certify vendors that will review the submitted disputes. Interested parties must submit a completed copy of the IDRE application and its attachments.

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IDRE Application and Certification

The Department seeks to certify vendors that will review the submitted disputes. Interested parties must submit a completed copy of the IDRE application and its attachments to the Department.

Completed applications and attachments must be submitted and received no later than 5:00 PM EST on January 13, 2023:

If you would like to submit your application and attachments electronically, contact us at [email protected] for further instruction on how to make your submission. Please do NOT submit your application to [email protected].
If submitting the application and attachments electronically, please be sure to submit your current fee information as a separate attachment clearly marked as “Fees”. If sending your application via overnight delivery, your current fee information should be placed in a sealed envelope marked “Fees” before being placed in the overnight delivery package with the application and remaining attachments.
Completed applications and attachments will also be accepted via overnight delivery to:

New York State Department of Financial Services
Consumer Assistance Unit
One Commerce Plaza
Albany, NY 12257

If submitting an application via overnight delivery, please also provide notice of the application submission to the [email protected] email address.

Applications are due no later than 5:00pm EST on January 13, 2023.

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Applicant Questions

Applicant questions are due no later than November 30, 2022.

Email questions to [email protected].

Responses to all questions will be provided no later than December 7, 2022. Responses will be emailed and posted on this page.

Independent Dispute Resolution Entity Application Questions and Answers

Questions and corresponding answers are not listed in any specific order. Questions may have been combined with similar inquiries.

Q 1. How many non-physician cases were received last year that did not require a New York licensed physician to make the determination?

A 1. Physicians are required to review disputes that involve physician services. To the extent practicable, the physician shall be licensed in New York. There were 139 non-physician disputes filed in 2021.

Q 2. What type of cases qualify as physician services versus facility based services?

A 2. Facility based services would involve disputes filed by a facility (hospital, ambulatory surgery center, etc.) and consist of charges being billed by the facility rather than a physician or other health care provider. Provider services would include disputes regarding fees billed directly by physicians or other healthcare providers who are acting within the scope of practice of that provider’s license or certification under applicable State law.

Q 3. If a physician is not required, what type of arbitrator is required?

A 3. Reviewers with training and experience in health care billing, reimbursement, and usual and customary charges who render dispute resolution determinations in consultation with reviewing physicians are also required.

Q 4. If a physician is required, offer or wishes to confirm that a physician with an active license in NY is required and that you are looking for a specialty match to the best extent possible?

A 4. Yes, as indicated above New York licensed physicians would be required to the extent practicable and would need to be in the same or similar specialty as the physician that rendered the service.

Q 5. Who are the current IDRE providers, and what are the current fees rates?

A 5. MCMC, KEPRO and IPRO are the current IDRE providers. Fee rates are as indicated below.

	IMEDECS/Kepro⁺	IPRO	MCMC
Full Review	395	375	300
Negotiation/Settlement	250	225	175
Application Processing Fee/Ineligible Rejection	150	105	100

Q 6. Approximately how many IDREs is the Department anticipating to award certification?

A 6. At this time DFS is looking to certify 5 IDREs

Q 7. What are the historical, annual volume of disputes for 2020 - 2022, broken down by number of disputes submitted, decisions rendered, settlement reached, and determined ineligible?

A 7. See below:

	2020	2021	2022*
Total Received	2,433	2,562	5,869
Not eligible	655	807	1,902
Decision issued	1,778	1,755	1,526
Settlement received	208	399	363
Patient filed dispute	19	18	10

* through 12/6/2022.

Q 8. What are the historical, annual volume of disputes for 2020 - 2022 involving uninsured patients and providers, and how many hardship waivers?

A 8. Uninsured patient disputes are in the chart above. DFS does not track the number of hardship waivers.

Q 9. What type of reporting is required to be submitted to the Department and how often?

A 9. DFS does not require any regular reporting.

Q 10. Are there template letters/forms that the Department would like IDREs to use for notification letters and decisions?

A 10. No, IDR Entities are required to create their own notices and decisions.

Q 11. How is data (i.e., dispute assignments, notices, decisions, etc.) transmitted to/from the IDRE? A portal, email, fax, mail, etc.?

A 11. The submitting party will enter basic dispute information into a Portal on the DFS website. The Portal will screen for potential duplicates, and if none are found will randomly assign the dispute to an IDR Entity. That Entity will receive email notice of the assignment. The submitting party receives a confirmation email that includes instructions to submit the application and supporting documents to the assigned IDR Entity. Each IDR Entity must be able to accept applications and supporting documents via US Mail, a dedicated fax number and electronically via email or a Portal.

Q 12. Is the IDRE responsible for purchasing the Fair Health database or is it the responsibility of the Payer to provide this data when submitting the dispute for IDR determination?

A 12. No, the health plans are required to provide this information.

Q 13. What would be the duties/responsibilities of the IDRE’s medical director licensed in NY pertaining to the dispute resolution process?

A 13. The Medical Director is responsible for overseeing the IDR process

Q 14. Can an IDRE reject a referral once submitted for reasons other than conflict of interest?

A 14. Yes, there are several reasons why a dispute might be rejected. See list below.

Assignment of Benefits Form not received by the insurer
Assignment of Benefits Form not signed
Assignment of Benefits Form received less than 30 days
Application incomplete
Application Not Received
Application Withdrawn
Administrative Services Only (self-funded)
Can’t determine eligibility
Claim paid in full, balance is member’s cost share
Date of Service Before 3/31/15
Duplicate
Essential Plan
Exempt ER Codes
Facility Charges
Federal Employee Program
Incorrect Date of Service
Incorrect Insurer
Medicaid ER Services
Medicare
No Response to Eligibility Inquiry
Not a Surprise Bill
Not an Emergency Service
Not Denied as Out of Network
Out of State Coverage
Out of State Facility
Paid according to fee schedule/negotiated rate
Participating Provider
Services Not Provided by a Physician
Settlement Prior to IDR
Timely Filing

Q 15. Regarding Attachment 2, are applicants required to list the names and information of the medical director and each reviewing health care provider and reviewer on the attachment? Section III.B. of the application appears to state that applicants should only provide the number and description, and types of cases they are qualified to review.

A 15. Yes Attachment 2 must list the reviewing health care providers and reviewers.

Q 16. The state references “Attachment XX,” which we assume is a placeholder. Please advise which Attachment is being referenced.

A 16. This would be Attachments 4 and 5 of the application.

Q 17. Please advise how fees are to be collected by the IDRE.

A 17. Each IDRE should bill the non-prevailing party, or both the health plan and provider for split decisions, when the decision is issued.

Q 18. If payment is to be paid by the “losing” party after the determination, are their requirements that payments be made timely? If yes, what is the time frame?

A 18. Payments due to an IDRE are required to be paid within 30 days from receipt of the decision and invoice.

Q 19. Are there penalties for non-timely reimbursements to the IDRE?

A 19. No, there are currently no penalties for late/non-payment of IDR fees

Q 20. Would DFS consider using the federal IDRE policy, wherein disputing parties pay the fee prior to conducting the dispute and the “winning” party is paid back their fee?

A 20. Not at this time.

Q 21. Must we submit the checklist with our application? If yes, in which section of the proposal should it be included?

A 21. Yes, the checklist must be submitted and should be placed in the same order as it is in the application.

Q 22. Please confirm we are solely to acknowledge receipt of and compliance with Attachments 4 and 5. If this is not correct, please advise.

A 22. Yes, applicants are required to acknowledge Attachment 4 and agree to comply if certified as an IDRE.

Q 23. What is the expected volume of cases?

A 23. While it is not possible to estimate the expected volume of cases, to date over 5,700 disputes have been submitted in 2022.

Q 24. What are the most common specialties involved in cases?

A 24. Plastic Surgery, Orthopedic Surgeons, Lab Services

Q 25. Are IDREs indemnified from lawsuit regarding decision rendered? Is there a law or regulation that states IDREs are indemnified from lawsuit?

A 25. New York Financial Services Law does not currently indemnify IDREs from lawsuits regarding decisions they rendered.

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