The Case for IDR: Why the Smartest Practices are Still Out-of-Network

In the past, out-of-network procedures allowed doctors to set their own rates and deliver quality care without being locked into underpaying, and convoluted payer systems.

With the passing of The No Surprises Act (NSA) in 2022, providers are now unable to balance-bill emergency out-of-network patients to make up the difference of what insurers won't cover. Doing so would constitute a "surprise bill" which is now federally illegal.

The NSA not only removed the ability to balance-bill, but also gave insurers the power to price out-of-network procedures according to their own opaque criteria. Many insurers have taken advantage of this new legislation to significantly underpay out-of-network procedures, justifying their payments under this new law.

What are the options?

Faced with underpayment, most providers give up and write off the underpaid claim as a loss. Alternatively, some providers attempt to negotiate privately with the insurers. Typically, this results in the provider accepting a less than favorable in-network contract with the insurer.

The third, rarely pursued option is the far more favorable option out of all three: initiating the Independent Dispute Resolution (IDR) process. IDR is a process built into the No Surprises Act (NSA) that gives provider groups and hospitals much needed leverage over insurers who abuse their ability to unfairly price procedures. Providers bring their claims to authorized entities (arbiters) to determine fair payment for these cases. IDR is "baseball arbitration", in which a third party entity issues a legally binding payment award by choosing either the provider's proposed amount or the insurer's proposed amount. If providers win, insurers are obligated to pay the provider's proposed amount within 30 days. The real kicker is how heavily favored providers are by the entities who arbitrate the IDR.

IDR: Providers are Winning and Winning Big

The data shows that IDR outcomes have been overwhelmingly favorable to providers. As of Q2 2024, providers have prevailed in the vast majority of determinations (~80%). With a strong claim, detailed research, and an expert team like MedResolutions filling claims, the win percentage can rise to upwards of 90%.

Source: KFF analysis of CMS data • Health System Tracker

Not only are the win rates high, but the payments awarded to providers are often significantly higher than the payment originally offered. In fact, they can even be multiples above the median in-network rate for the same service.

Source: KFF analysis of CMS data • Health System Tracker

The numbers show that despite the high success rate and payouts, IDR remains underutilized. A mere 6% of eligible cases were filed for IDR in 2024 (~1.2 million cases filed vs. 20 million cases eligible). Most practices and hospitals, therefore, likely have eligible cases that were underpaid, written off or settled, and ultimately never pursued through the favorable IDR process.

Source: AHIP & Blue Cross Blue Shield Association, No Surprises Act Survey Report, October 2025.

While it could be that roughly 75% of providers are happily accepting insurer's initial payments, the payment data that's been released thus far does not support this claim. In 2023, 94% of providers were still receiving initial payments that were priced at or even below Medicare. It is far more plausible that providers and RCM/billing companies are simply not aware of this process. IDR is a fairly new mechanism outlined amidst the No Surprises Act's extensive and complicated legislation.

Surprise Bills are Unavoidable

For providers and health systems, becoming in-network with every insurance provider is near impossible. With over 1,100 reporting health carriers and countless more small regional plans, it's only a matter of time before providers and health systems who work in emergency settings will encounter an out-of-network patient. Though these cases may represent a small percentage for organizations with diligent credentialing teams, they can have a disproportionate financial impact. Without IDR, any potential out-of-network encounter carries the risk of severe underpayment, administrative delays, and complex appeals that strain revenue cycles and distract from patient care.

Why Pursue IDR: A Moral Case

IDR is about maintaining autonomy in a system that pressures providers at every turn to accept unfavorable rates. In nearly every U.S. city, just one or two insurers dominate the market, giving payers outsized control over network rates and contract terms. Insurance contracts are not only problematic financially but dealing with insurance on a daily basis produces strain at every turn. AMA's 2024 survey work shows pervasive prior authorization burden, with 93 percent of physicians reporting delays to patient care, highlighting payer leverage in day-to-day operations as well.

Given insurance's power, out-of-network claims will be consistently underpaid. Our IDR strategy assumes, and accepts that this underpayment is both expected and foundational to the model. Rather than viewing underpayment as a failure, a practice or hospital should treat it as the starting point for a structured recovery process that can reimburse multiples above the initial offer. IDR is the leverage that provider groups, especially those who remain independent, desperately need.

Why choose MedResolutions?

Having a team behind your practice that can fight these cases, without adding administrative strain is crucial. IDR is not a simple task that an RCM staff member can juggle with numerous other responsibilities. It requires careful expertise and attention to detail.

Insurers are keen on disputing IDR cases based on minute details like missed deadlines and improper or incomplete submissions. With the right team, most, if not all of these ineligible cases can be avoided.

The MedResolutions team has a history of filing and winning IDR cases across many different specialists. Our edge has been carved out by hard-won familiarity with federal and state processes, access to market benchmarks that allow us to analyze reimbursement trends nationwide, and personal relationships that we have fostered with the third party entities who arbitrate these cases. By choosing MedResolutions, you're gaining access to a team and a growing set of technology tools that care about your practice as more than a number.

Ready to Recover What You're Owed?

If you're tired of accepting below-market reimbursement for out-of-network services, it's time to explore the IDR process. Contact us today for a free review of your claims and see how much revenue you might be leaving on the table.