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The Problem

The “No Surprises Act” rules create new protections against out-of-network balance billing and establish a new process, called independent dispute resolution (IDR), which providers (including air ambulance providers), facilities, and health plans can use to resolve payment disputes for certain out-of-network charges.

After disputes have been initiated, reviewed for conflict of interests and eligibility, and have received offers from at least one disputing party, the IDR Entity (IDRE) will then provide a payment determination based on the evidence submitted. This payment determination can either be sent through the Federal IDR Portal or manually outside the Federal IDR Portal.

The purpose of this user experience study is to understand the major pain points and goals the disputing parties (initiating and non-initiating) have when received payment determinations from the IDRE.

Payment Determination
for IDR

Problem

# User Research, # User Interview, # Usability Testing, # Qualitative Research

The Approach

Identify User Pain Points: Understand the specific pain points and challenges users related to Federal IDR payment determination and challenges related to payment.

Content Clarity and Understanding: Assess the initial and current clarity and comprehensibility of the emails and communications provided to parties.

Methodology: Semi-structured Interviews to evaluate users' experience of Federal IDR payment determination

Approach

The Process

Process

1. Planning and Preparation

Define research objectives, goals, and key questions.
Develop research protocols and interview/questionnaire guides

2. Recruitment and Scheduling

Recruit participants and schedule interviews
- Participant Profiles
  - Provider Profiles
    - Health Care Provider
    - Health Care Facility
    - Revenue Cycle Management Contractor
    - Practice Management Firm
  - Plans/Issuers Profiles
    - Group Health Plan
    - Individual Health Insurance Issuer
    - Third-Party Administrator
    - Cost Containment Firm
Prepare testing environments and tools
Train the research team and coordinate logistics

3. User Interviews

Conduct interview sessions with participants
- 60-minute interview with Zoom
- 9 participants from Iniaiting Parties
- 13 participants from Non-Initiating Parties
Gather qualitative and quantitative data on user interactions
Document observations, feedback, and pain points
Regularly debrief with the IDR team to discuss initial finding

4. Follow-up Research

Analyze data to identify patterns, themes, and insights
Prepare summary reports of follow-up research findings
Reach out to stakeholders with additional clarification/information

5. Data Analysis and Synthesis + Findings Report + Readout (Presentation)

Analyze all collected data from interview sessions and follow-up research.
Identify common themes, pain points, and opportunities for improvement.
Create findings presentation, journey maps, or other visualization tools to represent findings.
Prioritize findings/recommendations and convert these findings into Jira Tickets.

5. Follow-Up Synthesis

Perform additional analysis, dependent on the complexity of the research data collected.
Work with workstream stakeholders to identify potential adjustments or refinements based on the initial findings.
Collaborate with cross-functional teams to ensure the integration of research findings into ongoing project development.

Outcomes

The Outcomes

Create personas for Initiating Parties and Non-Initiating Parties
- Initiating Parties

Non-Initiating Parties

Design Payment Determination Notice templates

Provide recommendations on Payment Determination Notice forms (+14 UX Enhancements)
- "Guide IDREs to provide all required information by updating the Payment Determination UI to require separate responses for each field."
- "Include system logic that requires at least one determination factor be checked in favor of the prevailing party for each item or service."
- "Add the determination date to the Payment Determination template."

Provide findings and recommendations related to IDREs
(+13 Findings and +14 UX Recommendations)
- Findings
  - "Challenges arise in obtaining timely responses from IDREs, sometimes resulting in no response or delays of several weeks to a month."
  - "Participants question responsibility for the lack of response, whether it lies with CMS or IDREs"
  - "Both parties often experience delays in receiving payment determinations from IDREs, exceeding the 30-business day timeframe."
- Recommendations
  - "Create a dedicated Dispute Community Portal where parties can view their communication history."
  - "Provide POC details of IDREs, such as their email addresses and phone numbers, during selection."

Provide findings and recommendations related to eligibility determination
(+3 Findings and + 5 UX Recommendations)
- Findings
  - "IPs would like to know eligibility before paying fees and/or submitting offers."
  - "Despite completing the process and receiving a payment determination, parties occasionally withhold payment, citing dispute ineligibility."
- Recommendations
  - Eligibility review should be completed before offers are requested from parties.
  - Establish a list of acceptable documents for parties to submit as proof of eligibility.
  - Encourage IDREs to provide responses to information provided by Non-IPs during eligibility attestations.

* Due to the NDA restrictions, the final outcomes of this project are confidential and cannot be posted on this website. Please contact me if you are interested in learning more about this project.

The Problem

Payment Determination for IDR

The Approach

The Process

The Outcomes

Payment Determination
for IDR