A new story based on HaloMD’s award data does not account for health plans’ established processes used to reimburse for out-of-network care and understates the significant impact of ineligible disputes entering the arbitration process.
Health Plans Make Initial Payments for Out-of-Network Care
After a patient receives care from an out-of-network provider and the provider sends a bill to a health plan, the health plan submits an initial payment for covered out-of-network services (or, very rarely, a notice of denial). According to AHIP and BCBSA data, for most qualified independent dispute resolution (IDR) claims (76%), providers accepted initial payment offers without dispute.
If the provider believes the initial payment is insufficient, they can take a claim to independent dispute resolution (IDR) in hopes of an IDR entity (IDRE) awarding the provider a supplemental payment via the IDR process.
Health plans and employers pay the majority of IDR awards within 30 days. Errors in final determinations and disputes over eligibility can lead to payment delays, especially if those determinations are contested and under review by CMS.
Many Disputes Filed By Providers Are Ineligible For Federal IDR
Data from health plans and researchers have continued to show a high volume of ineligible disputes going through the IDR process, upwards of 40% in 2025. Ineligible claims include:
- Claims for services payable under Medicare or Medicaid;
- Disputes already resolved through IDR at the state level and resubmitted at the federal level;
- Disputes involving in-network providers; and
- Claims subject to a state surprise billing law.
Yet IDREs ultimately ruled only 17% of cases ineligible. That means more than half of the disputes flagged as ineligible still resulted in payment determinations and added administrative costs that should never have occurred in the first place.
Health plans and employers have a responsibility to safeguard members’ healthcare dollars. Every dollar spent on ineligible disputes filed by providers and associated administrative fees ultimately impacts the premiums paid by employers and families.
Providers’ False Flag on $0 Offers
Out-of-network providers have wrongly pointed to $0 offers as an indication of non-payment. A $0 IDR offer does not, by itself, establish that a health plan failed to make a required payment. Its significance depends on prior payments, the dispute’s eligibility, and the final determination. A $0 offer sends a clear signal that either:
- The plan or employer already made a sufficient initial payment on the claim.
- The dispute is for Medicare, Medicaid, state-based IDR, or is otherwise not eligible for the federal IDR process.
If a dispute should never have been filed, offering more money simply because it was filed would risk rewarding the filing and inviting even more ineligible disputes.
The Impact of Incomplete, Inaccurate IDR Determinations
When a payment for an eligible claim is delayed past the 30-day mark, the delay is usually a result of significant information gaps or inaccuracies with final determinations. Common reported problems include:
- Misdirected notices. Disputes are filed against the wrong health plan or with incorrect contact information, so the plan responsible never learns a payment is owed or receives a delayed notice.
- Incomplete determinations. IDR determinations can lack the information a health plan needs to adjudicate a claim or process a payment.
- Significant errors. Some determinations contain mistakes significant enough that they must be reviewed and appealed to CMS.
Addressing the Real Surprise Billing Problems
Payment information stripped of its context misses what’s driving the untenable costs for employers and consumers. Policymakers should focus on the real problem: keeping ineligible and duplicate disputes out of IDR, holding bad actors accountable, and ensuring the process works as Congress and the President intended.
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