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.

For eligible claims, the Independent Dispute Resolution (IDR) process provides a binding payment determination after unsuccessful open negotiation. A certified IDR entity reviews the parties' submissions and selects one of the final offers. Any amount due from one party to the other is generally payable within 30 calendar days after the determination.

What Current CMS Data Shows

CMS reported that certified IDR entities rendered 1,082,247 payment determinations in the first six months of 2025. Providers, facilities, or air ambulance providers were the prevailing party in approximately 88% of those determinations. That is a national process result—not a promise about any claim or a MedRes-specific win rate.

The same CMS release shows why screening discipline matters: non-initiating parties challenged eligibility in 40% of disputes initiated during the first half of 2025, and 17% of closed disputes were found ineligible. Strong outcomes among payment determinations do not eliminate the need to verify service category, plan type, state routing, deadlines, and documentation before filing.

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 may be underpaid. Our IDR strategy treats an insufficient initial payment as the starting point for a structured, claim-specific review. When a claim is eligible, the federal IDR process gives independent provider groups a formal path to seek additional reimbursement without guaranteeing any particular outcome.

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 may challenge IDR eligibility based on details such as missed deadlines and incomplete submissions. Complete data and disciplined screening can reduce preventable ineligibility, but the certified IDR entity makes the final eligibility determination.

The MedResolutions team supports IDR matters across multiple specialties. Our approach combines familiarity with applicable federal and state processes, market benchmarks for analyzing reimbursement trends, and technology-assisted case preparation. By choosing MedResolutions, you gain a team focused on careful, claim-specific recovery work without promises about any individual result.

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.