The federal Independent Dispute Resolution process decides out-of-network payment when a plan and a provider can't agree. Here's the two-stage path, the six factors an arbitrator weighs, what they're forbidden to consider, and the deadlines that quietly decide most cases.
The cheapest win comes before the arbiter. Most disputes should never reach IDR.
A 30-business-day, party-to-party window with no arbiter and no fee. Reach a number here and you skip the IDR fees and the coin-flip entirely. A QPA-anchored counteroffer is usually enough, because escalating to IDR costs the provider too.
Baseball-style arbitration: each side submits one number, and a certified IDR entity picks one — no splitting the difference. There's an administrative fee per party and the certified-IDRE fee. The offer that's defensible on the six factors wins.
The Qualifying Payment Amount (QPA) is the plan's median contracted rate for the same or a similar item or service in the geographic region, generally set from 2019 rates and indexed forward by the Consumer Price Index. It is the statutory anchor the arbitrator must consider in every case — and, critically, it is a contracted rate, not a billed charge. A defensible offer starts here.
Set by statute (42 U.S.C. § 300gg-111(c)(5)(C)) — the QPA plus five additional considerations.
The plan's median contracted rate for the service in the region. Considered in every case; the starting reference for a defensible number.
The provider's or facility's level of training, experience, and quality and outcomes measurements for the item or service in dispute.
The market share held by the out-of-network provider/facility, or by the plan, in the geographic region.
The acuity of the patient, or the complexity of furnishing the item or service.
The teaching status, case mix, and scope of services of the facility — for facility disputes.
Demonstrations of good-faith efforts (or their absence) to reach a network agreement, and any contracted rates between the parties over the previous four plan years.
The provider's billed or usual-and-customary charges, the amount that would have been billed absent the No Surprises Act, and public-payer rates (Medicare, Medicaid, CHIP, TRICARE). That's exactly why an inflated demand doesn't help a provider — and why a QPA-anchored, contracted-rate offer wins.
Most default losses aren't lost on the merits — they're lost on a missed window.
Avertyn scores eligibility, defends the QPA, and builds the offer an arbitrator can defensibly pick — filed on time, every time.