Dr. Brian Cruz Shared What Payors and Providers Need to Know About Independent Dispute Resolution

August 11, 2025 When payors and providers hit a wall of disagreement over reimbursement for healthcare services, Independent Dispute Resolution (IDR) becomes the last line of fairness. But the process only works if it's fast, impartial and grounded in clinical reality.

Dr. Brian Cruz, Medical Director of H.H.C. Group's New York IDR program, leads that effort. With over a decade of frontline clinical experience and a track record in arbitration oversight, he ensures that every decision reflects the right balance of regulation, documentation and medical standards.

In this Spotlight Interview, Dr. Cruz, a board-certified emergency physician with over 13 years of clinical practice in emergency and urgent care -- walks through the real work behind IDR — what drives fair outcomes, where most parties go wrong and why independent oversight is critical for protecting plan integrity in the surprise billing environment.

Q: What's your role in H.H.C. Group's IDR program?

A: I oversee the entire IDR process in New York, reviewing determinations, providing clinical direction, managing grievances and conducting internal audits to ensure consistency. We apply the same standards to every case. That's the only way this process earns trust from both payors and providers.

Q: Tell us about your background and how you got involved.

A: H.H.C. Group recruited me about three years ago to help stand up the IDR program from the ground level. I've also worked nationally on clinical policy and provider education, which gave me a strong foundation for building a process like this.

Q: Walk us through how the IDR process works.

A: It's a "baseball arbitration" model. We review submissions from both sides, usually providers and payors, to determine which proposed payment is more reasonable based upon the documentation, the CPT codes and regional reimbursement data. You can't split the difference. You have to choose a side for each code.

Q: What factors drive your final decision?

A: It starts with the documentation. If the CPT code doesn't match what was actually done, that claim doesn't hold. Then we evaluate what's typical for that CPT in the provider's geographic region. Both sides submit data as the basis for comparison, verification and determination of which number is more in line with standard reimbursements. The stronger case wins.

Q: How often does one side fail to submit solid documentation?

A: Roughly 10–15% of the time, one side fails to support their argument. When that happens, the outcome usually favors the side that did submit proper documentation. The takeaway is simple: if you don't back up your numbers, you're not likely to win.

Q: When do you step in personally?

A: I review any case involving a complaint, grievance or inconsistency flagged in our audit process. If a board-certified reviewer raises questions or lacks sufficient rationale, it comes to me. That's part of the integrity check, we don't let anything slide through unexamined.

Q: What quality controls are in place?

A: We audit randomly, monitor turnaround times and track resolution metrics across specialties. If a certain category shows a pattern of disputes, we investigate. Quality assurance is built into every layer of the process.

Q: How does H.H.C. Group stay aligned with state regulations?

A: Our legal counsel reviews questionable cases before we even begin. We don't accept disputes that fall outside regulatory boundaries. Once the case is accepted, we apply clinical best practices and ensure every outcome can stand up to scrutiny.

Q: What trends are showing up most frequently in IDR cases?

A: Early on, there was a lot of confusion over stabilization vs. post-stabilization care. Many providers misunderstood the criteria, assuming vitals alone determine stability. That's not the case. The definition is more precise and we've had to educate many stakeholders to close that gap.

Q: Why is independent oversight so essential?

A: Because both sides are financially motivated. Providers want higher reimbursement. Payors want to cut costs. Our job is to assess the facts, eliminate the noise and decide what's actually fair. For smaller providers in particular, the independent review process offers a level of fairness they don't get when dealing directly with payors.

Q: Do you see providers winning more often?

A: Yes, especially in cases where payors provide weak justification or undercut established norms. When providers submit strong documentation and regional benchmarks, they often make the stronger case. We side with payors just as easily when the data supports it. We don't pick winners, we follow the evidence.

Q: What should providers and payors understand about how this process works?

A: Support your case. That's the bottom line. Don't assume your position will hold unless it's backed by documentation. Whether you're billing or paying, submit what's necessary to justify your number. If you don't, the other side will.

Q: What part of this work do you find most impactful?

A: Being the one to bring structure and clarity to a messy process. These cases can get contentious. When we apply standards consistently and communicate clearly, it builds credibility. That matters. Everyone wants a fair shake and our job is to deliver exactly that.

Independent Reviews That Strengthen Plan Integrity

H.H.C. Group's IDR program goes beyond compliance. It delivers expert, evidence-based determinations that reduce risk, strengthen claim outcomes and build confidence in your plan administration. Every case is reviewed by board-certified specialists. Every decision is grounded in clinical standards and backed by full documentation.

What You Can Expect:

• Expert reviews of medical necessity and experimental/investigational care.
• Most determinations completed in 5–7 business days.
• <0.1% reconsideration rate, a mark of clinical consistency and accuracy.
• Regulatory alignment and vetting built into intake.
• Full documentation and audit trail to support every decision.

Ready to Test the Process?

Submit 15–20 claims under H.H.C. Group's "Proof in the Pudding" program and see firsthand how our IDR process holds up, on speed, accuracy and results.

Contact HHC Group to get started today.

Real People. Real Savings.