WHAT WE DO

When a health plan underpays your out-of-network claim, we help you challenge the payment and pursue fair reimbursement through IDR.

IDR is simple in theory but cumbersome in practice. Every dispute moves through a series of steps governed by strict deadlines, complex filing requirements and evolving federal and state laws. There's little room for error. One missed deadline or filing mistake can put your dispute at risk.

At Advantify, we combine healthcare-executive judgment with innovative technology to help streamline the process and help you recover the true value of your services.

Eligibility

Not every out-of-network claim is eligible for IDR. Knowing which claims can move forward is where our technology gives you an advantage.

We bring every step of IDR into one custom centralized platform. We review your claims for service type, network status, health plan coverage, filing deadlines and applicable federal or state rules.

Our technology and team screen claim eligibility with a 99.5% confidence level, helping us identify real reimbursement opportunities, catch potential errors and avoid unnecessary filings.

Negotiation

Open negotiation gives providers and payers 30 business days to resolve an OON payment before entering IDR. We manage the process from start to finish.

Our team builds your payment position using claim details, the Qualifying Payment Amount (QPA), reimbursement data, historical settlements and relevant market information. We present your position to the payer, manage communications and evaluate counteroffers.

We work with you to determine when to negotiate, settle or move forward. If the dispute remains unresolved, we initiate IDR within the required four-business-day window after the negotiation period ends.

Submission

Federal IDR has one of the tightest filing windows in the process, with just four business days after open negotiation ends to initiate a dispute. There's little room for error.

We specialize in federal IDR and applicable state dispute processes, determining the correct path for each claim and managing their different filing requirements and deadlines.

Our team maps payer behavior, payment patterns and dispute trends to help develop a reasonable offer supported by evidence.

We finalize your reimbursement packets, handle submissions and manage every deadline through determination, so your team doesn't have to.

Reimbursement

Federal IDR follows what's known as baseball-style arbitration. You and the payer each submit a final payment offer to a certified IDR entity (IDRE). The entity must choose one or the other. It can't split the difference.

Our team monitors the review process to keep you informed as the dispute moves toward a decision. But a favorable determination doesn't mean the money has been collected.

We follow up on outstanding payments and help reconcile what was awarded against what was received. You'll know where your case stands, what payment is due and what has actually been collected.