How often do providers win federal IDR disputes?
Verdict Consulting Group Research · Updated
Answer
Providers win most federal IDR payment determinations. CMS reports that providers, facilities and air ambulance providers prevailed in about 85% of determinations from July 1 to December 31, 2025, and about 88% from January 1 to June 30, 2025. In the second half of 2025, the prevailing offer exceeded the QPA in about 87% of determinations.
Detail
CMS figures, second half of 2025
| Measure | Jan 1 – Jun 30, 2025 | Jul 1 – Dec 31, 2025 |
|---|---|---|
| Payment determinations | 1,082,247 | 1,145,039 |
| Provider-side prevailing share | 88% | 85% |
| Health plan prevailing share | — | 14% |
| Default decisions (share of determinations) | 22% | 17% |
| Provider win rate, non-default decisions | 87% | 84% |
| Prevailing offer above the QPA | — | 87% |
Source: CMS, Supplemental Background on Federal IDR Public Use Files, July 1 – December 31, 2025 (released July 22, 2026). A default decision occurs when one party fails to submit an offer or pay fees.
Context
Emergency department services made up 52% of determinations in the second half of 2025 and radiology 15%. CMS notes that plans often benchmark offers to the QPA, while providers often benchmark to past out-of-network payments and in-network rates. Figures change with each quarterly release; cite the period and release date.
Read the analysis
Sources
- Centers for Medicare & Medicaid Services — Supplemental Background on Federal IDR Public Use Files, July 1 – December 31, 2025 ()
- Centers for Medicare & Medicaid Services — Independent dispute resolution reports ()
General information only, not legal advice. Verdict Consulting Group is not a law firm.