Short answerYes. Independent out-of-network physicians can use federal IDR for claims covered by the No Surprises Act: emergency services, and non-emergency services furnished by out-of-network providers at in-network facilities, under plans subject to the Act. Some state-regulated plans use a state process instead, and Medicare and Medicaid are excluded.
Large hospital systems and staffing companies filed most early IDR disputes. Independent groups are often eligible too, and many have never filed.
Which claims qualify
- emergency services by out-of-network providers
- non-emergency services by out-of-network providers at in-network hospitals, hospital outpatient departments, critical access hospitals and ASCs
- air ambulance services
Common physician examples: anesthesia, assistant surgeons, radiology, pathology, neurophysiology and emergency medicine at in-network facilities.
Which plans
| Plan | Federal IDR? |
|---|---|
| Self-funded employer plans (ERISA) | Generally yes |
| Fully insured plans in states without a specified state law | Generally yes |
| Fully insured plans in states with their own process | State process may apply (Texas has one) |
| Medicare, Medicaid, TRICARE | No |
What makes a strong offer
- the provider's training, experience and outcomes
- case complexity and patient acuity
- prior contracted rates with the plan, if any
- market share of the parties
- good-faith efforts to contract
Is it worth it?
It depends on the gap between the payment and a fair rate, the number of similar claims that can be batched, and the federal fees. We review each claim before filing and charge 10% only on amounts recovered.
Related: what is the QPA.
This article is general billing information, not legal or coding-compliance advice. Payer rules, CPT descriptors and federal guidance change; check the current versions for your claims.