Unpacking the Offers: What Three Years of Data Do and Don’t Reveal About Insurer Behavior in IDR

By Kennah Watts and Jack Hoadley

Since its implementation in 2022, the independent dispute resolution (IDR) process within the No Surprises Act (NSA) has caused much controversy between providers and insurers. Our prior analysis of public data published by the Centers for Medicare and Medicaid Services (CMS) indicates that providers win the vast majority of IDR disputes, with a median award nearly 4.5 times median in-network rates (as represented by the qualifying payment amount or QPA). While insurers allege that this success is the result of providers gaming the process and acting fraudulently––with some even accusing provider-side middlemen of racketeering––providers argue that their win rates are justified in part by insurers’ lack of engagement in arbitration. Providers contend that insurers’ default rate and submission of “lowball” offers in arbitration leave the arbitrator no choice but to side with providers under the NSA’s baseball-style arbitration rules.  

Through analysis of the public use files (PUFs) and supplemental documents published by CMS, we examined what public data reveal about insurer engagement and offers in IDR (excluding air ambulance disputes). As discussed below, while the PUFs provide useful insights, more transparency could shed further light onto this process.

Insurers Default on Roughly a Fifth of Disputes

In federal IDR, default disputes occur when one party fails to engage in the process by not submitting an offer or not paying the associated arbitration fees. Since 2023, the CMS-reported default rate has fluctuated, but generally about a fifth (15 percent to 22 percent) of quarterly disputes are default determinations. While in 2023 the rate of default was fairly evenly split between providers and insurers (59 percent in favor of providers), default determinations in 2025 were nearly always (91 percent) in favor of providers. 

Although providers are now far more likely to win default disputes, these determinations do not seem to affect providers’ overall win rates in arbitration. Indeed, providers’ overall win rates are relatively unchanged when default disputes are excluded, suggesting that default disputes are not a significant driving factor in high provider win rates. The analysis presented below excludes default disputes.

Insurer Initial Payments and Offers are Consistently At or Above the QPA

CMS recently added the insurer’s initial, pre-IDR payment to providers to the PUFs. Insurers reported paying providers a median initial amount of 90 percent of QPA. When providers rejected this initial payment as too low and initiated the IDR process, insurers offered more than their initial payment in more than 70 percent of disputes. In fact, from 2023 through 2025, insurers almost always (approximately 90 percent of disputes) offered an amount at or above the QPA during the arbitration process (see Table 1). In most quarters, insurer offers were more often above QPA than at the QPA, though by a small margin. 

Table 1. Share of Insurer Offers Below, At, or Above the QPA, by Quarter

“Lowball” Dollar Amount Offers from Insurers are Few but May Be Growing

In dollar amounts, rather than a percent of QPA, insurers infrequently submitted “lowball” offers. For example, the share of insurer offers between $0 and $1 is relatively low: in seven of the 12 quarters with data, less than 5 percent of insurer offers were $1 or less (Table 2). Over the three-year period, these nominal offers occurred in about 500,000 disputes, accounting for roughly 6 percent of all disputes resolved through 2025. However, the share of low dollar offers may be increasing, with peaks at 12 and 10 percent in mid-2025.

Table 2. Share of Insurer Offers Between $0 and $1, by Quarter

When Insurers Up Their Offers, Their Win Rate Remains Unchanged

In non-default determinations, insurers tend to offer amounts centered around their median in-network rate. A recent analysis by Paragon Health Institute found that in some instances where insurers offered many multiples of the QPA during arbitration, their win rate did not improve. These unchanged win rates also hold true when insurers’ median offer increased and when insurers made higher outlier offers. In 2024, insurers offered a median award of 110 percent of QPA, up from 100 percent of QPA in 2023 (Table 3). Insurers fare no better even though they have made higher outlier offers over time. In 2023, the top 10 percent of insurer offers exceeded 161 percent of QPA, whereas in 2025, the top 10 percent of offers exceeded 274 percent of QPA. Despite these higher median and outlier offers, insurers’ overall win rates remain consistently around 15 to 20 percent, while providers continue to win greater median award amounts. 

Table 3. Distribution of Insurer Offers as a Percent of QPA by Year

Additional Data Could Help Untangle Allegations Made By Parties

While the PUFs shed some light on the federal arbitration process, much remains unclear. For example, in several ongoing lawsuits, insurers assert that default rates are at least partly attributable to provider behavior. Plans argue that providers’ mass submission of disputes in a short period of time (sometimes in a single day), as well as intentional filing of ineligible disputes, prevent them from engaging in all filed disputes. 

Eligibility is another area that warrants greater transparency. Supplemental files from CMS reveal that insurers challenge eligibility in roughly 40 percent of disputes, while IDR entities find only 10 to 20 percent of disputes ineligible each quarter. Without an explanation from IDR entities on why disputes are eligible (or not), it is difficult to assess the validity of either figure.

At the same time, providers have questioned the validity of the QPA methodology and contend that the QPA calculation depresses rates. While several published studies have attempted to assess the accuracy of the QPA––including studies backed by providers and insurers––there is no definitive consensus among these studies. However, a full panel of the Fifth Circuit recently found that the QPA methodology improperly excluded certain incentive-based payments and improperly included so-called “ghost rates” (i.e., non-negotiated rates for services that a provider does not offer). The ruling will likely require guidance from CMS about how to proceed with QPA calculations in light of the Fifth Circuit’s decision (which has been appealed in part to the Supreme Court). The recalculations are expected to increase QPA values, but the size of the increase is unclear. 

Providers have also turned to the courts to seek enforcement of IDR awards and to obtain prompt payment. Providers have long maintained that insurers do not pay IDR awards within the specified time frame, if at all. But without record of payment in the PUFs or elsewhere, these claims cannot be substantiated beyond the allegations brought in litigation or identified in investigative journalism. 

Looking Forward

The NSA was designed to protect patients from certain surprise balance bills while encouraging insurers and providers to negotiate a fair out-of-network rate for covered care. When these negotiations fail, the IDR process makes a binding payment determination. Despite the guardrails Congress intended to place on the IDR process, the current IDR system has not produced the balanced outcomes initially anticipated, resulting in significant cost implications for employers and patient premiums. As policymakers on both sides of the aisle consider reforms to the IDR process, more transparency into the process and parties’ incentives could help ensure Congress pursues evidence-based solutions.