Out-of-Network Providers Are Winning in IDR: What Healthcare Leaders Need to Know

Since the No Surprises Act (NSA) went into effect in 2022, out-of-network (OON) providers have increasingly relied on the federal Independent Dispute Resolution (IDR) process to recover fair payment for their services. And the results are clear: when providers engage in IDR, they tend to win—and win big.

Recent data shows that out-of-network providers are recovering 2 to 3 times more than standard in-network rates, with success rates as high as 86% in arbitration. As the financial stakes rise, so does the need for a smart, streamlined strategy to capitalize on this opportunity.

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Why IDR Matters for Out-of-Network Providers

The IDR process was designed to resolve payment disputes between insurers and providers for emergency and certain non-emergency services. When insurers underpay or deny full reimbursement for services delivered by OON providers, those providers can take the case to IDR.

Unlike traditional appeals or denials management, IDR is binding, fast, and statistically favorable for providers—when approached with precision.

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The Numbers: Providers Are Prevailing

• Win Rates Up to 86%: In 2023, providers won 86% of IDR disputes, according to research published in Health Affairs (Chhabra, 2024).
• Payouts ≈ 3× QPA: The same study found that arbitration awards were 2.7 times the Qualifying Payment Amount (QPA) on average.
• Median Awards 3.7× Medicare: For emergency, imaging, and neonatal services, median IDR awards were at least 3.7 times the Medicare benchmark (ACR, 2023).
• CMS Data Confirms Trend: CMS reported that providers prevailed in 77%–80% of IDR determinations in 2023 (CMS Federal IDR Reports, 2024).

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What This Means for Revenue Cycle Leaders

For hospitals and provider groups operating partially out-of-network, these outcomes can represent significant financial recovery opportunities—but only with the right infrastructure in place.

Key Takeaways:

• Strategic Case Selection is Essential
  Not every dispute is IDR-worthy. Focus on claims where reimbursement fell substantially below QPA or historical in-network rates.
• Documentation Drives Outcomes
  Arbitration entities weigh provider submissions heavily. Include market-based comparables, historical rates, CPT-level data, and robust rationales.

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How NYX Health Helps Providers Win in IDR

At NYX Health, we empower providers to navigate the IDR process with confidence. Our service supports:

• IDR case identification
• Pre-built document templates for arbitration
• Real-time QPA benchmarking
• Charge master optimization
• Integrated good faith estimate workflows

With high average recovery and provider-favored rulings, IDR is more than compliance—it’s a strategic financial lever. Let us help you pull it.

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The No Surprises Act has permanently changed the financial landscape for out-of-network care. With most disputes ending in provider victories and award amounts well above payer benchmarks, now is the time to take control of your IDR strategy.

Don’t leave revenue on the table. Let NYX Health help you with the process and insights needed to win. Contact us today!

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Sources

• Chhabra, K. (2024). High Out-of-Network Payment Awards Through the Federal IDR Process. Health Affairs. https://doi.org/10.1377/hlthaff.2023.01048
• Centers for Medicare & Medicaid Services. IDR Operations Reports. https://www.cms.gov/nosurprises/Help-resolve-payment-disputes
• American College of Radiology. NSA Arbitration Trends. https://www.acr.org
• U.S. GAO. Implementation of the No Surprises Act. https://www.gao.gov