The IDR Scoreboard

There is a second appeals system in American health care, and almost no clinician who fights denials will ever touch it. It is not for denied claims. It is for a narrower fight: what an out-of-network provider gets paid when a patient could not choose in-network — the emergency room, the anesthesiologist a patient never met, the air ambulance. The Federal Independent Dispute Resolution (IDR) process, created by the No Surprises Act, is the referee for that payment fight. And on the public record, one side is winning almost every round.

Read the scoreboard with care: the numbers come from different CMS releases covering different periods, and the win share counts the initiating party, not literally “providers.” Those distinctions decide what the figure means — the methodology note below spells them out. But the shape does not move. Across every reporting period CMS has published, the party that brings the dispute wins the large majority of the time, and the volume keeps outrunning every projection made when the law passed.

The distinction is the whole reason this scoreboard sits apart from the rest of this publication. A denial appeal contests whether a service is covered — medical necessity, prior authorization, coding. IDR never asks that question. By the time a case reaches IDR, everyone agrees the service happened and is owed something; the only open question is the dollar amount of the out-of-network rate. CMS puts it plainly: the process lets out-of-network providers and plans “determine the OON rate for qualified IDR items or services after an unsuccessful open negotiation period.”³

It is also structurally different. IDR is baseball-style arbitration: each side submits one final offer, and a certified IDR entity picks one — not a number in between. The winner is simply whichever party’s offer the arbiter selects, which is what CMS records as the prevailing party.³ And it only applies to the surprise-billing scenarios the No Surprises Act defines: emergency care, and non-emergency care delivered by out-of-network clinicians at in-network facilities, plus air ambulance transport. For how the process starts and who qualifies, see our explainers on the No Surprises Act IDR process and the underlying surprise medical bill protections. If your denial is a coverage or medical-necessity denial, IDR is not your road.

When the No Surprises Act was written, the federal government expected the arbitration channel to be a relief valve used rarely — on the order of 17,000 disputes a year.⁴The actual traffic has been in a different universe. CMS’s own supplemental report documents 610,498 disputes initiated in the first six months of 2024 — 56% more than the 390,346 in the last six months of 2023.² The 2025 PUF then recorded roughly 1.2 million disputes in the first half of 2025, more than double the same window a year earlier.¹ The referee has been buried: certified IDR entities closed 460,774 disputes in H1 2024 but still left a growing queue of cases awaiting a determination.²

The traffic is not evenly spread. A small number of large practice-management and revenue-cycle firms drive most of it: in the first half of 2024, the top ten initiating parties accounted for roughly 69% of all disputes, and the top three alone — Radiology Partners, SCP Health, and Team Health — for about 44%.² This is a channel worked hard by a few sophisticated repeat players, not a tool the average small practice reaches for.

The fight concentrates in a handful of service lines — the ones where out-of-network billing at in-network facilities is structurally unavoidable. In CMS’s H1 2024 report, two categories carried roughly two-thirds of every payment determination:

And when the arbiter picks a winner, the winning number tends to sit well above the plan’s benchmark. CMS reports that the prevailing offer was higher than the qualifying payment amount (QPA)— the plan’s median contracted rate, the figure the law nudges offers toward — in roughly 85% of payment determinations in the first half of 2024.² CMS cautions that low-dollar services show the largest percentages because a small absolute gap becomes a large percentage gap, so the specialty-level ratios in its supplemental tables should be read as directional, not as a uniform multiplier.²

The headline win share deserves an asterisk that CMS itself supplies. The 84% figure for H1 2024 is not one clean contest. CMS separates it: providers won a 86% share of determinations where both parties submitted an offer and paid their fees, but a larger 75% share of default decisions — cases the arbiter had to award to the only party that submitted an offer and paid, because the other side did not.² Default wins are real dollars, but they are a different event from a contested decision on the merits of the offers.

One more caveat rides underneath all of it: eligibility. Before any offer is weighed, a certified IDR entity must confirm the dispute even belongs in IDR — and a large share do not survive that gate. Non-initiating parties (the plans) challenged the eligibility of 45% of disputes initiated in H1 2024, and 18% of disputes closed in that period were determined ineligible.² The win share is measured on the disputes that clear eligibility and reach a payment determination — not on everything filed.

Running the arbitration is not free to the parties. Every disputing party pays a non-refundable administrative feeto CMS on top of the certified IDR entity’s own fee. For disputes initiated on or after January 22, 2024, that administrative fee was $115 per party per dispute; CMS’s Federal IDR Operations final rule then cut it to $15 per party per dispute for disputes initiated on or after June 11, 2026.⁵ On a channel processing hundreds of thousands of cases a quarter, the entry fee is its own line of the ledger — one we will track as the lower fee takes effect in the next release.