IDR filing for pathology groups

Why pathology is structurally exposed

Pathology is on the list of ancillary services where notice and consent can never be used. If the specimen came from a patient at an in-network facility, the patient owes in-network cost sharing and the plan decides what to pay you. There is no fallback to the patient — the only remedy is the dispute process.

The volume problem

• Per-claim amounts are small relative to emergency or anesthesia claims, so single-claim filing rarely justified the old $115 administrative fee.
• The 2026 final rule dropped that fee to $15 per party and widened batching to include same-service-code groupings and consecutive-day services for a single patient, capped at 50 items.
• That combination moved a large block of pathology claims from "not worth filing" to "worth filing in batches."

What we do for pathology groups

• Screen the full out-of-network remit file for eligibility rather than cherry-picking large claims
• Build batches by payer and service code to the 50-item cap
• Construct offers on complexity, subspecialty expertise, and comparable determinations — never on billed charges, which arbitrators may not consider
• Track awards to payment within the 30-calendar-day window