What does an IDR underpayment audit check?
Verdict Consulting Group Research · Updated
Answer
An IDR underpayment audit compares each award with what federal rules require the plan to pay: the selected offer, less the initial payment and patient cost sharing, paid within 30 calendar days of the determination. It can also test whether the initial payment or denial arrived within 30 calendar days of the bill and carried the required QPA disclosures.
Detail
The federal benchmarks an audit tests against
| Check | Federal requirement | Source |
|---|---|---|
| Initial payment timing | Initial payment or notice of denial within 30 calendar days after the bill is transmitted | 42 U.S.C. 300gg-111(a)(1)(C)(iv)(I) |
| QPA disclosure | Information about the QPA provided with the initial payment or denial | 45 CFR 149.140(d) |
| Award amount | Selected offer, less the initial payment and cost sharing paid or owed | 45 CFR 149.510(c)(5)(ix) |
| Award timing | Payment within 30 calendar days after the determination | 45 CFR 149.510(c)(5)(ix) |
| Settlement timing | Payment within 30 calendar days after an agreement is reached | 45 CFR 149.510 |
What the results are used for
The output is a dated, claim-level record of each determination, the payment due date and what arrived. That record matters because remedies differ by court: some courts allow suits to enforce awards and others do not (see Can a provider sue to enforce an IDR award?). For disclosures required on or after August 3, 2026, the 2026 Federal IDR Operations rule added content to the QPA disclosure requirements.
Sources
- Electronic Code of Federal Regulations — 45 CFR 149.510 — Independent dispute resolution process ()
- Legal Information Institute, Cornell Law School — 42 U.S. Code § 300gg-111 — Preventing surprise medical bills ()
- Electronic Code of Federal Regulations — 45 CFR 149.140 — Methodology for calculating qualifying payment amount ()
General information only, not legal advice. Verdict Consulting Group is not a law firm.