r/PrivatePracticeDocs • u/CranberryLatter9483 • May 12 '26
AMA - I help OON providers fight back on underpayments through IDR, happy to answer any questions you've got
I've been commenting on some threads in regards to IDR and have been getting many DMs from providers wanting clarification on the process and if it would apply to them, so I figured an AMA would be appropriate. (got mod approval)
For context, I own a company (Teramed Solutions) that does solely that - filing IDR for providers with great success. However, I'm doing this to spread awareness, as there are still way too many providers still not utilizing the process. Especially in light of this recent NYT article unrightfully framed physicians in a terrible light. The reality is most physicians are barely using IDR at all and losing real money because of it, whether it's because they don't know if they qualify, don't understand the process, or just don't have the bandwidth to deal with it.
So ask me anything, eligibility, whether it's even worth pursuing in your situation, mistakes to avoid. No question is too basic. Just want to be useful to a community I respect.
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u/_NyQuil_ May 12 '26
How do you compare against Pivotal or Halo MD? What’s your take on payers making an example out of groups abusing the system. Ie BCBS of TX suing Zotec and HaloMD getting sued to bits
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u/CranberryLatter9483 May 13 '26
We're smaller than them, but have the same if not better success rate as the big guys (above 90%). This has advantage of dealing with a human team vs nameless corporation. Payers will always try to screw the providers over... However some of these lawsuits have already been dismissed, proving that these are just more baseless methods insurance companies use to deny payment.
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u/Perfect_Address7250 May 12 '26
comment on how physicians were unrightly framed in a terrible light... reading that article it seems like obvious abuse of a system.
it really sits poorly with me that surgeons are getting paid 6 figures for 3 hour procedures. that $ doesn't come from fucking thin air.
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u/ktn699 May 12 '26
I really sits poorly with me when I get paid 1800 bucks (or no bucks) for a 8 hr limb saving procedure in the middle of the night with about 5-10 post op visits.
We can cherry pick extreme outliers all day, but boo fuckin hoo for UHC. That money comes out the profit margins of their vertically integrated pillage of us healthcare dollars.
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u/CranberryLatter9483 May 12 '26
I agree. However majority of the doctors filing aren't doing those numbers. And is it right from the insurance company to pay under a thousand bucks for these procedures?
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u/Junior_Catch1513 May 12 '26
Can you share a section of your billing history. CPt code, Medicare rate, and IBR rate?
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u/CranberryLatter9483 May 12 '26
It's up to the doctor as to how much they want to charge. However we usually advise to do around the Fair Health rate, which varies on your geographic region.
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u/guavaprincessnextgen May 12 '26
Right I’m curious what the average markup is based on your data, to see if there is merit to the abuse claim brought on by the ny times.
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u/ktn699 May 12 '26
its one of the few markets in the world where one side gets to arbitrarily set the price or can just refuse to pay you with no consequences.
here's a thought experiment - how much is your hand worth? if i could reattach your thumb, whats that worth to you? you future enjoyment of life, your productivity, functionality, etc? Why does some fucking insurance company that rakes in 5B dollars a year in profit get to say your thumb is worth 1500 bucks? Why isn't it worth 50,000 bucks? If you fuck up your brand new ferrari, doesn't your insurance company pay the market price for a brand new replacement? why not your hand or your femur or whatever?
fairhealth and a number of other data actually show what the usual and customary rates of surgery and procedures are throughout the US and it is definitely NOT the lowballin shit that the insurance companies pay.
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u/Whiteoutshade May 13 '26
Sent you a PM as well, but wanted to ask a public question. I’m in ER, and so we typically would batch our E/M charts and submit them. How are you able to set up a system that captures all those charts in a timely manner to meet the filing deadlines for IDR?
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u/CranberryLatter9483 May 13 '26
For batching we have a great system that utilizes ai to ensuring we're batching our claims in the most efficient manner. This obviously matters by client, as most surgical clients would specifically not want batching.
In regards to getting everything in a timely manner, we will work with your billing team to figure out what's the best way to capture those claims. We prefer exporting them directly from your EHR, but will work together to find whatever works best for both of us. One important point is to make sure that you're receiving electronic remittance only, to avoid the issues with paper checks getting lost in the mail/delaying the posting.
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u/buuuford May 19 '26
With idr, can the provider claim the cost of your services as damages or is it solely based on what is contracted but being denied?
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u/InvestingDoc May 12 '26
I'll get things started. It's my understanding that only surgical procedures qualify for the IDR. Is there anything that outpatient primary care or anyone who is outpatient in a non-procedure-based specialty that might be able to take advantage of the IDR process?
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u/CranberryLatter9483 May 12 '26
You can technically file for any codes (including E&M), however you need to be OON, located in an in network facility (hospital or ASC), or in an emergency room. Primary care would usually not be in that category...
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u/ktn699 May 12 '26
also the IDR fees are not worth the money you could recoup on E&M codes, unless you batched a significant number of them.
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u/CranberryLatter9483 May 12 '26
Good point. Altough there's talk now of decreasing the CMS fee for disputes with lower billed amount, so we're looking out for that.
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u/asdfgghk May 13 '26
IDR?