What is an IDR underpayment audit?
Verdict Consulting Group Research · Updated
Answer
An IDR underpayment audit is a claim-level review that matches each federal IDR determination to what the health plan actually paid. It checks whether the plan paid the selected offer, less the initial payment and patient cost sharing, within 30 calendar days of the determination, and classifies each award as paid, short-paid, late or unpaid.
Detail
The four outcomes
| Classification | Meaning |
|---|---|
| Paid | The amount owed arrived within 30 calendar days of the determination |
| Short-paid | A payment arrived, but for less than the selected offer minus the initial payment and cost sharing |
| Late | The amount owed arrived after the 30-calendar-day deadline |
| Unpaid | No payment toward the award has arrived |
The deadline and the amount owed come from 45 CFR 149.510(c)(5)(ix) and 42 U.S.C. 300gg-111(c)(6). For the full list of checks an audit can run, including initial-payment timing and QPA disclosures, see What does an IDR underpayment audit check?.
Verdict Consulting Group offers IDR underpayment audits for provider groups and their counsel.
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 ()
- Verdict Consulting Group — IDR underpayment audits for provider groups ()
General information only, not legal advice. Verdict Consulting Group is not a law firm.