Common Questions About the IDR Process

No. Before the law was enacted patients and providers bore tens of billions of dollars in costs. When patients had encounters with out-of-network providers, they could face large medical bills for that care, leading to out-of-pocket costs and the potential for bankruptcy. Providers also had large costs for uncompensated and undercompensated care when patients failed to pay for services.

Those specific costs and personal bankruptcies have largely been eliminated by the NSA. In fact, many stakeholders, including health plans, acknowledged that the law will save consumers significant amounts of money. Further, compared to traditional dispute mechanisms such as litigation or arbitration, the IDR process is highly cost-effective, saving money for all stakeholders — particularly consumers. The cost to parties of resolving payment disputes through the IDR process is typically less than $1,500 per dispute, and in many instances even lower. Thus, compared with the costs of other plan-provider disputes, the IDRE process saves significant amounts, benefiting all stakeholders, and reducing costs for consumers.

The cumulative number of cases going through the system over the past four years reflects the number of surprise bills that patients have now avoided, and the number of cases between out-of-network providers and health plans that need to be resolved. The volume is neither excessive nor insufficient; it simply reflects the number of disputes that must be considered. The insurance industry estimates that in 2024 there were 20 million out-of-network claims in total, only about 2 million of which went through the IDR process, meaning that 90% were resolved by the Plans and the providers without any third-party assistance.

A 2021 CMS estimate led Congress to publish an expectation of approximately 17,000 claims per year through the IDR system. That estimate, however, was based on the experience of one (New York) state program, which operated in a very different manner than the NSA. As a result, the early estimate was not an accurate predictor of how the federal program would work. Further, as would be expected of any new federal program, the number of cases going through the IDR program has increased over time. This volume simply reflects the actual number of payment disputes that would previously have resulted in surprise bills. In truth, Congress and CMS did not know how many claims would be involved, and built a system that could accommodate whatever volume of disputes was necessary to protect patients from surprise medical bills.

As with any new program, the IDR process has needed to grow and develop systems and efficiencies. A backlog of disputes developed in 2023-24 following the large influx of new disputes and multiple, litigation-related pauses imposed by CMS. However, once the program resumed, IDR entities rapidly cleared most of the accumulated cases. Today, many IDR entities are meeting CMS timeliness expectations for processing disputes.

No, the data shows that at present providers “win” a majority of the disputes going through the IDR process. This outcome does not reflect a flaw in the system nor a bias on the part of the IDR entities. Congress created a “baseball style” arbitration process through which each side of the dispute submits one offer, which is measured against specific statutory criteria set by Congress. The IDR entity cannot compromise between offers.

They must select the offer that best represents the value of the IDR item or service, taking into account criteria set by Congress (which are known by the parties). As parties gain experience and calibrate their offers more closely to the statutory criteria, outcomes are expected to become balanced between providers and insurance plans.

No, at the time the NSA was enacted an estimated 90% of treatments were provided by in-network providers, and in 2026 the Government Accountability Office found that since the IDR process was implemented, provider in-network participation rates have increased from 90% to 93%.

The process only applies to providers who were out-of-network when they treated the patient and, by definition, did not agree to any in-network rate. Moreover, Congress set the criteria for payment using multiple factors beyond the "Qualifying Payment Amount" (QPA) that plans historically paid in-network providers. In other words, Congress intended awards to exceed typical in-network rates, and the awards have been consistent with Congressional design.

Yes, but they are being weeded out. The eligibility criteria are complex, and parties are still filing ineligible claims. IDR entities must currently identify and dismiss these claims, often at significant cost to the IDR entity. CMS is working on a regulation to streamline the eligibility process and CIDRE hopes that the regulation will be finalized soon.

Yes. Due to a 2025 court decision, prevailing parties to an IDR decision do not have the right to enforce their judgment in court, and it is up to CMS to create the enforcement process when a party chooses not to honor the IDR entity award.