New York State IDR: The Structure Nobody Talks About

Most of the noise in the non-par space is about everything except how New York state IDR is actually built. Almost nobody talks about the structure behind it: who runs the forum, what number the law names, and what clock runs on a determination. Eliott Dear thinks that is a mistake.

The Regulator Runs the Forum

New York state IDR is administered by the Department of Financial Services—the same agency that licenses and regulates every fully-insured health plan selling coverage in the state. The dispute is heard in a forum run by the insurer’s own regulator.

When Eliott Dear files a New York state IDR dispute, the submission is a purpose-built legal document signed under his bar number: FAIR Health 80th percentile benchmarks, geographic analysis, and the procedure-specific facts of the claim, built as a full documented package rather than a form with a number on it.

FAIR Health 80th Percentile

New York state IDR uses FAIR Health 80th percentile as its benchmark—built from what providers in a given geography actually charge for a given procedure. It is the benchmark named in New York law.

FAIR Health is an independent nonprofit that aggregates billed-charge data from across the industry. When an arbitrator is looking at the NYC FAIR Health 80th percentile for a given CPT code, the arbitrator is looking at an independent, verifiable number. FAIR Health is not a party to the proceeding.

The 80th percentile is not a number either side picks. The statute names it, and every submission is built around it.

DFS Authority

DFS does more than run the forum. It licenses the carrier on the other side of it.

New York’s Department of Financial Services has full authority to revoke an insurer’s license to do business in the state. That is not a theoretical power. And when a New York state IDR determination comes down, it carries a 30-day payment deadline.

That is the structure. The agency that licenses the carrier is the agency that runs the forum, and the determination comes with a deadline attached. Claims Assassins tracks that deadline on every dispute it files.

Why Nobody Talks About It

The state IDR framework is boring. It has an independent benchmark, a statutory payment deadline, and a regulator with license authority. Every piece of it is written down. Nothing to write a press release about.

That is exactly why Eliott Dear built Claims Assassins around it. Boring rules call for discipline: the right benchmark, the right documents, the right deadline, every time.