Independent Dispute Resolution, run properly
When a health plan underpays an out-of-network claim and negotiation fails, Independent Dispute Resolution is the federal process that settles it. It is deadline-bound, procedurally exacting, and it is where a great deal of emergency-group revenue currently goes uncollected.
Regulatory information reviewed as of 2026-08-16. Federal dispute rules are amended periodically; this page is re-checked quarterly.
Who this is for
Is this you?
- Emergency medicine groups with material out-of-network volume and payment rates they believe are below a defensible benchmark
- Urgent care centres and facility-based specialties treating patients whose plans place them out of network
- Air ambulance and other providers covered by the federal surprise-billing framework
- Groups whose current billing company does not offer dispute resolution and writes underpayments off instead
The problem
What this is actually solving
Underpayments are being absorbed rather than disputed
When a plan pays an out-of-network claim well below a defensible rate, the difference is no longer billable to the patient and frequently gets posted as a contractual adjustment. Nobody decided to accept it; it simply fell outside what the billing process was set up to handle, and it recurs every month.
Deadlines expire before anyone assesses the claim
The windows for open negotiation and for initiating a dispute begin running from the payment or denial notice. A claim nobody looks at for six weeks is often a claim that can no longer be disputed at all, regardless of how strong its merits were. Timing is the most common way these are lost.
The economics are never worked out
Administrative fees apply per dispute, so some claims are not economic to run alone while batched claims can be very worthwhile. Without someone modelling that, groups either dispute nothing or dispute indiscriminately, and both approaches lose money in different ways.
Scope
What's included
- Eligibility assessment, determining which claims qualify for the federal process and which fall under a state process instead
- Benchmark and payment analysis to establish whether a claim is worth disputing at all
- Open negotiation with the payer, initiated and documented within the applicable window
- Offer preparation with supporting documentation assembled for the certified IDR entity
- Dispute initiation, entity selection and submission through the federal portal
- Batching assessment where related claims may be submitted together
- Tracking to determination, with outcomes reported back against the claims they relate to
- Deadline monitoring across the whole book so nothing lapses unassessed
Scope & engagement model
Where this service ends and another begins. Stating it plainly keeps engagements clean and means every positive claim on this page is one you can hold us to.
- Legal representation or advice. we prepare and submit disputes, not legal counsel
- Routine claim submission and follow-up, which is covered under Medical Billing
- Patient balance billing, which the surprise-billing rules prohibit for these claims in any case
How we do it
The process
Specific to this service, not a generic four-step onboarding diagram reused across every page.
- Step 01
Identify and qualify
We screen paid and denied out-of-network claims against the federal eligibility criteria, separating those covered by the federal process from those falling under a state dispute process, and flag anything with a deadline already running.
- Step 02
Assess whether it is worth running
Each qualifying claim is compared against the payment benchmark and the applicable administrative fees, individually and as part of any batch it could join. Claims that will not recover their own cost are reported to you as such rather than quietly run up a bill.
- Step 03
Open negotiation
We initiate and document the negotiation period with the payer. A meaningful share of disputes settle here without proceeding further, which is faster and cheaper for everyone, so this stage is worked properly rather than treated as a formality.
- Step 04
Prepare and submit the offer
Where negotiation does not resolve it, we assemble the submission: the offer, the supporting documentation, and the rationale, and file it through the portal within the window, handling certified entity selection as part of the process.
- Step 05
Track and report
Disputes are tracked to determination and the outcome is posted back against the original claim, so the recovered amount appears in your reporting rather than arriving as an unexplained payment months later.
An out-of-network claim is paid below a defensible rate. First the claim is assessed for eligibility, separating claims covered by the federal process from those under a state process. Then an open negotiation period runs with the payer, and many disputes settle here. If negotiation does not resolve it, independent dispute resolution is initiated, a certified entity is selected, and both parties submit an offer. The entity chooses one of the two submitted offers, so the determination is one side's number rather than a midpoint. Deadlines run from the payment or denial notice, and a missed window ends the claim regardless of its merits. Claims are also assessed for whether they are economic to run, individually or batched.
Track record
What we have done with it
- 42,000+
- Claims submitted through federal IDR
- 96%
- Determinations awarded to our offer
Source: Federal IDR portal records. Figures as of August 2026.
Outcomes
What changes for your practice
- Out-of-network underpayments become a worked category with a defined process instead of a recurring adjustment
- Disputes are filed inside their windows, so claims are lost on merit rather than on timing
- You see which claims were disputed, which settled in negotiation, and which were judged uneconomic to run
- Batching is assessed as a matter of routine, which changes the economics for lower-value claims
FAQ
Questions we get asked
Do you handle state dispute processes as well as the federal one?
Qualification includes determining which framework applies, since several states run their own processes that displace the federal one for certain plans. Which state processes we currently handle directly is confirmed during onboarding. Where we do not, we tell you rather than filing into the wrong process and losing the claim.
Who pays the administrative fees?
Fee responsibility is agreed as part of the engagement, and it is one of the first things to settle because it drives which claims are worth running. What matters more than who pays is that somebody has modelled the economics per claim and per batch before anything is filed. That analysis is part of the service.
Can you run disputes on claims another company billed?
Yes. IDR can be engaged standalone against claims someone else submitted, and this is a common way groups start with us. It works better alongside routine billing, because deciding what to dispute is easier when you can see payment patterns across the whole book, but it does not require it.
How current is this information?
The rules governing this process have been amended more than once since they took effect, through both rulemaking and litigation. The payment benchmark methodology, administrative fees and batching eligibility have all moved. This page carries a review date and is re-checked against current federal guidance quarterly rather than left to drift.
Compliance
- HIPAA-compliant processes across every engagement
- Our team has completed HIPAA training
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Start with a free billing audit
We review a sample of your recent claims and your current A/R aging, and report where revenue is being lost. The report is yours whether or not you engage us.