An Analysis of No Surprises Act (NSA) Independent Dispute Resolution (IDR) Emergency Service Outcomes Relative to InNetwork Rates
Congressional research reportFeb 10, 2026
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An Analysis of No Surprises Act (NSA)
Independent Dispute Resolution (IDR)
Emergency Service Outcomes Relative to
In-Network Rates
February 10, 2026
Congressional Research Service
https://crsreports.congress.gov
R48851
SUMMARY
An Analysis of No Surprises Act (NSA)
Independent Dispute Resolution (IDR)
Emergency Service Outcomes Relative to
In-Network Rates
R48851
February 10, 2026
Ryan J. Rosso
Specialist in Health Care
Financing
The No Surprises Act (NSA), part of the Consolidated Appropriations Act, 2021 (P.L. 116-260),
established various consumer protections related to surprise billing—that is, circumstances in
which individuals receive large, unexpected medical bills when they are unknowingly, and potentially unavoidably, treated
by out-of-network (OON) providers.
The NSA also specifies a methodology to be used to determine how much insurers must pay OON providers for care in
specified situations. Under the federal payment methodology, when an insurer and an OON provider cannot agree on the
relevant payment amount, either party may initiate an independent dispute resolution (IDR) process before a private
arbitrator. In a process commonly described as “baseball-style” arbitration, the insurer and provider each submit to the IDR
entity an amount representing what the party believes the total price of care should be (i.e., a payment offer), and the IDR
entity then selects between the parties’ payment offers.
Since the IDR process became operational in April 2022 and through 2024, its utilization has exceeded initial expectations,
with over 2 million initiated disputes. Providers have initiated nearly all disputes, and have been very successful in the IDR
process; in 2023 and 2024, the IDR entity selected the provider’s offer in approximately 80% and 85%, respectively, of the
disputes that resulted in a payment determination.
Emergency service disputes represent the most common type of dispute. The median prevailing offers for emergency service
disputes ranged from 2½ to 3 times the qualifying payment amount (QPA) in 2023 and 2024. The QPA is a statutory
benchmark defined as an insurer’s 2019 median in-network rate for a particular item or service furnished by a provider in the
same/similar specialty and location, indexed for inflation.
The QPA is a significant part of the IDR process and has been a focus of interest groups during NSA implementation.
Providers have expressed concern about the lack of QPA transparency and have asserted that insurers are incorrectly
determining the QPA. Insurers have indicated that the QPA represents the market rate for services.
Outcomes from the IDR process affect health care costs through payments that insurers make to providers for OON care and
can affect subsequent negotiation of in-network rates between insurers and providers. The Congressional Research Service
(CRS) analyzed IDR process emergency service outcomes in 14 states against the in-network rates of IDR-participating
providers to compare QPAs, insurer and provider offers, and prevailing offers.
For IDR emergency service disputes determined in the first half of 2024, (1) over 95% of disputes had a prevailing offer that
was above the 2025 median in-network rate among IDR-participating providers, and (2) the median prevailing offer in the
IDR process for emergency service was over three times the 2025 median in-network rate among IDR-participating
providers. In addition, (3) the median QPA was slightly higher than the 2025 median in-network rate of IDR-participating
providers.
Further analysis by state highlights that (1) in all 14 states assessed, the median prevailing offer for emergency service
disputes determined in the first half of 2024 was greater than the 2025 median in-network rate of IDR-participating providers;
however, (2) the degree to which the median prevailing offer exceeded the median in-network rate of IDR-participating
providers varied by state. In Nevada and California, the median prevailing offer was slightly higher than the median innetwork rate, whereas Colorado saw a median prevailing offer that was over six times the median in-network rate of
Colorado IDR-participating providers. In total, nine states had a median prevailing offer that was more than three times the
median in-network rate. Additionally, (3) the relationship between the QPA and median in-network rates varied across states.
In six states, the median QPA was less than the median in-network rate; in eight states, it was greater than the median innetwork rate.
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IDR Emergency Service Outcomes Relative to In-Network Rates
Contents
Background ..................................................................................................................................... 2
Qualifying Payment Amount..................................................................................................... 3
Transparency in Coverage In-Network Rates ........................................................................... 4
Data and Methods Overview ........................................................................................................... 4
Datasets ..................................................................................................................................... 5
Methods ..................................................................................................................................... 5
Data Limitations ........................................................................................................................ 7
Analytical Findings ......................................................................................................................... 8
Aggregate Analysis ................................................................................................................... 9
State-Level Analysis................................................................................................................ 10
Summary and Policy Implications................................................................................................. 13
Figures
Figure 1. Distributions of IDR Emergency Service QPA, Offers, and Outcomes Relative
to Median In-Network Rates ........................................................................................................ 9
Figure 2. Median IDR Emergency Service QPA, Offers, and Outcomes Relative to
Median In-Network Rates, by State ............................................................................................ 11
Tables
Table 1. Percentage of IDR Emergency Service Disputes Where Provider Was the
Prevailing Party, by State ........................................................................................................... 12
Table B-1. IDR Dispute Characteristics ........................................................................................ 19
Appendixes
Appendix A. Methods.................................................................................................................... 15
Appendix B. Selected Characteristics of IDR Dispute Sample Used for Analysis ....................... 19
Contacts
Author Information........................................................................................................................ 20
Congressional Research Service
IDR Emergency Service Outcomes Relative to In-Network Negotiated Rates
he No Surprises Act (NSA), part of the Consolidated Appropriations Act, 2021 (P.L. 116260), established various consumer protections related to surprise billing—that is,
circumstances in which individuals receive large, unexpected medical bills when they are
unknowingly, and potentially unavoidably, treated by out-of-network (OON) providers.1 The law
generally recognizes surprise billing circumstances to include OON emergency services, OON
nonemergency services provided during a visit at an in-network facility, and OON air ambulance
services. In those situations, the NSA generally limits the amount consumers pay for care and
specifies a methodology to be used to determine how much insurers must pay OON providers for
care.2
T
Under the federal payment methodology, when an insurer and an OON provider cannot agree on
the relevant payment amount, either party may initiate an independent dispute resolution (IDR)
process before a private arbitrator, referred to as an IDR entity.3 In a process commonly described
as “baseball-style” arbitration,4 the insurer and provider each submit to the IDR entity an amount
representing what the party believes the total price of care should be (i.e., a payment offer). The
IDR entity selects between the parties’ payment offers after considering a list of statutory factors,
including the item’s or service’s qualifying payment amount (QPA). The QPA is defined as an
insurer’s 2019 median in-network rate for a particular item or service furnished by a provider in
the same or similar specialty and location of service, indexed for inflation. Each participant pays
a flat fee to participate in the IDR process, and the non-prevailing party also pays the IDR entity’s
fee.
The Congressional Budget Office (CBO) has indicated that outcomes from the IDR process can
affect health care costs in at least two ways. First, the IDR process directly determines payments
that insurers make to providers for OON care. Second, in general and more broadly, IDR
outcomes can affect costs through subsequent negotiation of in-network rates between insurers
and providers, where insurers or providers can leverage the threat of the provider being OON and
having the ability to use the IDR process to obtain lower or higher in-network rates.5 Both sets of
costs have implications for premiums and, subsequently, the federal budget.
Given the potential implications of the IDR process on health care costs, researchers have sought
to analyze and contextualize IDR outcomes through several approaches. Studies, for example,
have examined IDR outcomes relative to QPAs and concluded that the median IDR outcome for
emergency services generally ranged from roughly 2½ to 3 times QPA in each quarter in 2023
and 2024.6 Another series of studies compared IDR outcomes to Medicare rates and found that
1 Surprise billing requirements were codified in Title XXVII of the Public Health Service Act (PHSA), Part 7 of the
Employee Retirement Income Security Act of 1974 (ERISA), and Chapter 100 of the Internal Revenue Code (IRC).
2 For ease of reading, this product uses the term insurer to refer collectively to both health plans and issuers. Similarly,
this product generally uses the term provider to refer collectively to both providers and facilities.
3 See 42 U.S.C. §300gg-111(c). For more information on the federal independent dispute resolution (IDR) process, see
CRS In Focus IF12073, Surprise Billing: Independent Dispute Resolution Process.
4 See Katie Keith, “Health Care Providers Fight Arbitration Rule in No Surprises Act,” Commonwealth Fund (blog),
March 17, 2022, https://www.commonwealthfund.org/blog/2022/health-care-providers-fight-arbitration-rule-nosurprises-act.
5 In the Congressional Budget Office’s (CBO’s) scoring of the No Surprises Act (part of the Consolidated
Appropriations Act, 2021 [P.L. 116-260]), roughly 80% of the net budgetary effect was attributable to changes in
prices for in-network care. Daria Pelech, CBO’s Approach to Estimating the Budgetary Effects of the No Surprises Act
of 2021, CBO, March 7, 2024, https://www.cbo.gov/system/files/2024-03/59878-Pelech.pdf.
6 For example, see CRS Report R48738, No Surprises Act (NSA) Independent Dispute Resolution (IDR) Process Data
Analysis for 2024; Jack Hoadley et al., “Independent Dispute Resolution Process 2024 Data: High Volume, More
Provider Wins,” Health Affairs Forefront, June 11, 2025; Erin L Duffy et al., “No Surprises Act Independent Dispute
Resolution Outcomes for Emergency Services,” Health Affairs Scholar, vol. 2, no. 11 (November 2024).
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IDR Emergency Service Outcomes Relative to In-Network Negotiated Rates
the mean IDR decision for emergency services in the second half of 2023 was four times the price
Medicare would pay.7
This CRS report contributes to the existing literature by using a more contemporary and marketbased benchmark of IDR-participating providers’ in-network rates, offering a distinct perspective
on the extent to which IDR determinations for services provided OON diverge from the
negotiated in-network rates of providers that participate in the IDR process. As such, this report
analyzes a subset of IDR outcomes for OON emergency services in selected states relative to
certain available data on in-network emergency services rates of IDR-participating providers.
Specifically, this report uses the in-network rates of providers from selected states that (1) CRS
identified as having participated in at least one IDR emergency service dispute in the first half of
2024, (2) had in-network rates that were reported by health insurers under the Transparency in
Coverage requirements in May 2025, and (3) had in-network rates that were included in a
database maintained by Payerset, an aggregator of transparency data. There were 14 states
included in this analysis, which were selected to minimize the effects of geographic variation
between underlying datasets.
This report begins with a brief background on the IDR process and an overview of the data
sources, data limitations, and methods used for this research before describing the analytical
findings. It concludes with a summary and potential policy implications. A more thorough
description of the methods can be found in the Appendix A, and a table describing different
selected characteristics of the IDR disputes analyzed in this report can be found in Appendix B.
Background
From when the IDR process became operational on April 15, 2022, through 2024, over 2.3
million disputes were initiated, far exceeding initial expectations.8 Providers initiated nearly all of
these disputes and have been very successful in the IDR process. In 2023 and 2024, the IDR
entity selected a provider’s offer in approximately 80% and 85%, respectively, of the OON
emergency and nonemergency service disputes that resulted in a payment determination.9
Dispute prevalence and outcomes vary by specialty. Emergency service disputes represented the
most common type of dispute (over 50% of all determinations in 2023 and roughly 45% of all
determinations in 2024). Median prevailing offers for emergency service disputes ranged from
2½ to 3 times the QPA in each quarter in 2023 and 2024 and were 4 times Medicare rates in the
second half of 2023.10
In the IDR process, the Centers for Medicare & Medicaid Services (CMS) has indicated that
providers often benchmark their offers to historical OON payment amounts with the disputing
7 For example, see Matthew Fiedler and Loren Adler, Outcomes Under the No Surprises Act Arbitration Process: A
Brief Update, Brookings Institution, July 31, 2024, https://www.brookings.edu/articles/outcomes-under-the-nosurprises-act-arbitration-process-a-brief-update/ (hereinafter Fiedler and Adler, Outcomes Under the No Surprises Act
Arbitration Process).
8 CRS Report R48738, No Surprises Act (NSA) Independent Dispute Resolution (IDR) Process Data Analysis for 2024.
Office of Personnel Management; Department of the Treasury, Internal Revenue Service; Department of Labor,
Employee Benefits Security Administration; Department of Health and Human Services (HHS), Centers for Medicare
& Medicaid Services (CMS), “Requirements Related to Surprise Billing; Part II,” 86 Federal Register 55980, October
7, 2021.
9 CRS Report R48738, No Surprises Act (NSA) Independent Dispute Resolution (IDR) Process Data Analysis for 2024.
10 CRS Report R48738, No Surprises Act (NSA) Independent Dispute Resolution (IDR) Process Data Analysis for
2024, and Fiedler and Adler, Outcomes Under the No Surprises Act Arbitration Process.
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IDR Emergency Service Outcomes Relative to In-Network Negotiated Rates
insurer and historical in-network rates with the disputing insurer or a different insurer in that
state.11 Insurers often benchmark their offers to their QPA for the particular item or service.12
When selecting between insurer and OON provider payment offers, IDR entities are allowed to
consider a list of statutory factors, including the QPA, and information related to specified
“additional circumstances.” These additional circumstances may include the provider’s level of
training, experience, and quality and outcome measurements; the market shares held by the
insurer and the provider; the individual’s acuity; the teaching status, case mix, and score of
furnished services; demonstration of good faith efforts made by the insurer and the provider to
enter into network agreements; contracted rates from the previous four years between the insurer
and the provider; and additional information submitted by parties regarding their offer.13
IDR entities are prohibited from considering usual and customary charges; the provider’s billed
charges; and Medicare, Medicaid, TRICARE, and other public payer rates for the disputed
service.14
Qualifying Payment Amount
The QPA plays a significant role in the IDR process. In addition to serving as a statutorily defined
factor considered by IDR entities and a common benchmark for insurers in the IDR process, it
serves as the amount used to determine consumer cost sharing in surprise billing situations.15
The QPA is an insurer-specific cost measure for a particular service. The insurer generally
determines the QPA as the median contracted rate for a service among all 2019 contracts with
providers in the same or similar specialty within each applicable insurance market and in the
same geographic region, as adjusted for inflation according to the Consumer Price Index for all
Urban Consumers (CPI-U).16 Insurers provide the QPA and selected QPA information to
providers with an initial payment (or denial of payment) for OON billing services, a step that
precedes the IDR process in the federal methodology.17
Providers and insurers have expressed differing opinions on the QPA.18 Providers have expressed
concern about a lack of QPA transparency and have pointed to instances of particularly low QPA
rates that are below Medicare rates as evidence of potential inaccurate calculation of QPA by
11 HHS, Department of Labor, and Department of the Treasury, Supplemental Background on Federal Independent
Dispute Resolution Public Use Files January 1, 2024-June 30, 2024, p. 4, https://www.cms.gov/files/document/
supplemental-background-federal-idr-puf-january-1-june-30-2024-march-18-2025.pdf.
12 HHS, Department of Labor, and Department of the Treasury, Supplemental Background on Federal Independent
Dispute Resolution Public Use Files January 1, 2024-June 30, 2024, p. 4, https://www.cms.gov/files/document/
supplemental-background-federal-idr-puf-january-1-june-30-2024-march-18-2025.pdf.
13 See 42 U.S.C. §300gg-111(c)(5)(C). This methodology does not apply in all situations. If a state has its own surprise
billing law that pertains to a given plan type, provider type, or service, the state law methodology would apply. In
addition, if a state has an all-payer model agreement, the amount designated under the agreement would apply.
42 U.S.C. §300gg-111(a)(3)(K).
14 See 42 U.S.C. §300gg-111(c)(5)(D).
15 See 42 U.S.C. §300gg-111(a)(1)(C)(iii).
16 See 42 U.S.C. §300gg-111(a)(3)(E).
17 See 45 C.F.R. §149.140(d).
18 Petra W. Rasmussen et al., The Implications of the No Surprises Act on Contract Dynamics, Negotiations, and
Finances, RAND Health Care, December 2024, pp. 16-18, https://aspe.hhs.gov/sites/default/files/documents/
754f61834289cdd719b542035ee36eba/PRA-1820-9.pdf (hereinafter Rasmussen et al., Implications of the No Surprises
Act.
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IDR Emergency Service Outcomes Relative to In-Network Negotiated Rates
insurers.19 In addition, providers have argued that certain implementing methodological features
artificially lower the QPA.20 Insurers, by contrast, have indicated that the QPA represents the
market rate for services.21 Insurers also are required to share certain information with OON
providers about the QPA upon an initial OON payment and upon a provider’s request, and IDRrelated rulemaking (and proposed rulemaking) around these disclosures has focused on finding a
balance between ensuring meaningful, transparent QPA reporting and minimizing administrative
burden.22
CMS is statutorily required to conduct QPA audits.23 To date, it has released one audit, where it
found the insurer was incorrectly determining air ambulance QPAs.24 CMS has conducted
additional audits as part of its investigations of complaints but has yet to release findings.25
Transparency in Coverage In-Network Rates
In 2020, the Departments of Health and Human Services (HHS), Labor, and the Treasury
(hereinafter, the Departments) issued the Transparency in Coverage final rule. The rule mandated
that insurers publish in-network negotiated rates with providers for all covered services and items
(excluding prescription drugs under a fee-for-service arrangement) on a publicly accessible
website for each offered plan, make the files available free of charge and without conditions, and
update them monthly.26
Some private vendors have emerged to aggregate, clean, standardize, and analyze Transparency in
Coverage data. One such vendor is Payerset, which provided in-network rates for this analysis
under a contract with CRS.
Data and Methods Overview
This CRS report looks to identify how IDR outcomes, provider offers, insurer offers, and QPAs
for emergency services compare with the in-network emergency service rates of the providers
participating in the IDR process. To do this analysis, this report uses selected data from the
Departments’ IDR and health insurer transparency data to calculate, for each OON emergency
19 See 45 C.F.R. §149.140(d). Rasmussen et al., Implications of the No Surprises Act.
20 For example, the inclusion of rates for services with providers regardless of whether the provider actually provides
that service (commonly referred to as ghost rates), which is currently the subject of ongoing litigation. For more
information on this case, see “Litigation over the QPA Methodology and Disclosure Requirements” in CRS Legal
Sidebar LSB11036, Overview of Selected No Surprises Act Litigation.
21 Rasmussen et al., Implications of the No Surprises Act, p. 17.
22 For example, see Office of Personnel Management, Department of the Treasury, Department of Labor, HHS,
“Federal Independent Dispute Resolution Operations,” 88 Federal Register 88494, December 21, 2023, p. 88504.
23 See 42 U.S.C. §300gg-111(a)(2).
24 CMS, Final Report: Federal Qualifying Payment Amount Audit of Aetna Health Inc. (a Texas corp.) – HIOS ID
#58840, Audit Report: 58840– 2022 – FED – QPA-1, https://www.cms.gov/files/document/qpa-final-report-aetnatx.pdf.
25 See 42 U.S.C. §300gg-111(a)(2)(A)(ii). CMS, 2022 and 2023 Qualifying Payment Amount Audits, April 2024, p. 5,
https://www.govinfo.gov/content/pkg/CMR-HE22-00196150/pdf/CMR-HE22-00196150.pdf; and Department of the
Treasury, Department of Labor, HHS, “Federal Independent Dispute Resolution (IDR) Process Administrative Fee and
Certified IDR Entity Fee Ranges,” 88 Federal Register 75744, November 3, 2023, p. 75764.
26 See 42 U.S.C. §300gg-15a and 45 C.F.R. §147.212(b)(1)(i). The Transparency in Coverage final rule contained other
provisions, such as the requirement for insurers to disclose certain price comparison information to enrollees through a
self-service tool and the requirement to publish out-of-network (OON) allowed amounts and billed charges. More
information on these requirements can be found in the “Price Comparison Tool” and “Transparency in Coverage”
sections, respectively, of CRS Report R45146, Federal Requirements on Private Health Insurance Plans.
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service dispute, the IDR outcome, provider offer, insurer offer, and QPA as a percentage of the
applicable median in-network rate for the same service, among all IDR-participating providers in
the same state, and whether provided by an individual provider or a facility.
This section briefly describes the datasets and methods used to conduct this analysis and selected
data limitations. A more in-depth discussion of the datasets and methods appears in Appendix A.
Datasets
Three datasets were used to conduct the analysis. Two of these datasets are available in public-use
files (PUFs) released by the Departments containing IDR dispute data,27 and the third is insurer
price transparency data provided by Payerset.
The first PUF dataset is OON Emergency and Nonemergency data (i.e., the Details File) for Q1
and Q2 of 2024. This dataset contains specific characteristic details for each party to an IDR
dispute, such as provider National Provider Identifier (NPI), provider name, insurer name, service
code, place of service code, and type of service code, but does not have dollar values for the
applicable QPAs, insurer offers, provider offers, and prevailing offers. Instead, a dispute’s
applicable QPA, insurer offer, provider offer, and prevailing offer are presented as a percentage of
other benchmarks (e.g., the prevailing offer is presented as a percentage of the QPA). This file
includes the state where the disputed service was provided.
The second PUF dataset is the QPA and Offers data (i.e., the Outcomes File) for Q1 and Q2 of
2024. This second dataset contains dollar-specific QPAs, insurer and provider offers, the
prevailing offers, service code, place of service code, and initiating party for each dispute but
does not contain specific, identifying information about the parties participating in each dispute.
This dataset includes the metropolitan statistical area (MSA) where the service was provided.
The Payerset data (i.e., Transparency Data) contains all May 2025 in-network emergency service
rates for a curated list of providers that were identified by CRS in the PUF Details File to have
participated in at least one IDR emergency service dispute in the first half of 2024 and whose
rates are within the Payerset database. Rates are associated with over 40 different insurers,
including Aetna, Blue Cross Blue Shield, Kaiser, and United. Data reported by plans under
Transparency in Coverage requirements do not include geographic variables (e.g., state).28
Methods
To conduct this analysis, the PUF Details File was used to identify providers that furnished an
applicable OON emergency service that was subject to an IDR dispute. That provider list was
used to extract corresponding negotiated in-network rates from the Transparency Data, which was
then trimmed to better align the data with the PUF datasets. The PUF Details File then was linked
to the Transparency Data using the provider NPI variable, allowing the provider state reported in
the Detail File to be assigned to the negotiated rates in the Transparency Data.29
27 Both the OON Emergency and Nonemergency data (i.e., the Details File) and the Qualifying Payment Amount
(QPA) and Offers data (i.e., the Outcomes File) are found on separate sheets in the Federal IDR Public Use File (PUF)
file. See CMS, “Independent Dispute Resolution Reports,” https://www.cms.gov/nosurprises/policies-and-resources/
reports.
28 For the price transparency schema, see CMS, “In-Network File,” https://github.com/CMSgov/price-transparencyguide/tree/master/schemas/in-network-rates.
29 If a provider furnished an applicable emergency service that was subject to an IDR dispute in the PUF Details File,
the state where the disputed service was provided was assigned to all of that provider’s in-network rates. In some
(continued...)
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Transparency Data were then used to calculate state level median in-network rates for a given
service across all insurers and providers. More specifically, median rates for a given service were
calculated based on each unique combination of billing code, state, and whether the provider was
an individual provider or a facility; the median was calculated across all negotiated rates between
insurers and the providers in the state that participated in an emergency service dispute that was
resolved in the first half of 2024.30 For example, the median in-network rate among all Texas
IDR-participating providers for a physician’s billing of a low-level emergency room visit (CPT
code 99283) was $117.62.31
To prepare a trimmed version of the PUF Outcomes File (consisting of applicable emergency
service disputes) to link with the Transparency Data, a state was assigned to each IDR dispute in
the trimmed PUF Outcomes File based on the MSA. There are differences in the level of
geographic detail between the PUF Details File, which is used to assign a provider’s state in the
Transparency Data, and the PUF Outcomes File—the PUF Details File lists geographies at the
state level, and the PUF Outcomes File lists geographies at the MSA level. Since MSAs can span
state lines, the analysis was restricted to include only states in which at least 95% of a state’s
trimmed emergency service disputes occurred in an MSA that was entirely encompassed within
that state.32 The following 14 states met this criterion: Alabama, Arizona, California, Colorado,
Connecticut, Florida, Idaho, Louisiana, Michigan, New Mexico, Nevada, Texas, Utah, and
Washington. Among disputes within these states, in instances where a dispute occurred in an
MSA that was located entirely within a state, that state was assigned to the dispute in the PUF
Outcomes File. In instances where a dispute occurred in an MSA that spanned state lines, the
dispute was assigned the state that was both (1) included in the MSA and (2) included in this
analysis.33
Transparency Data median rates were linked with the applicable emergency service disputes in
the PUF Outcomes File using the following variables: assigned state, dispute service code, and
whether the rate/dispute related to an individual provider or a facility. After linking, each dispute
items’ QPA, insurer offer, provider offer, and prevailing offer were then calculated as percentages
of the applicable median in-network rate by dividing each of those values by the applicable
median in-network rate.
In total, over 82,000 disputes were analyzed for this report, which represented about half of the
total sample of emergency services disputes.
instances, providers had multiple disputes and the state of the disputed service varied across the disputes. For these
providers, all provider in-network rates were designated as applying in each state in which there was at least one
relevant dispute.
30 Medians were not weighted and do not account for differences in the numbers of negotiated rates that each provider
had or the number of IDR disputes that a provider participated in.
31 Emergency department visit CPT codes range from 99281 to 99285 and are coded based on increasing levels of
complexity associated with the visit, with service code 99281 representing the least complex and service code 99285
representing the most complex.
32 For purposes of this calculation, the total number of trimmed state emergency service disputes included any dispute
that occurred in an MSA that contained at least a portion of the state.
33 Only two states, Texas and Washington, had analyzed emergency service disputes occur in an MSA that crossed state
lines; these disputes accounted for roughly 1% of analyzed disputes within each of these states. In both of these
instances, the disputes were assigned as occurring in Texas or Washington, as applicable.
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Data Limitations
Data collection timeline differences, in-network rate data challenges, missing billing code
modifiers, and geographic variable differences created certain limitations with this analysis.
First, the PUF Files and the Transparency Data are from different time periods. The PUF Files are
for disputes resolved during the first half of 2024 and include services provided in 2022 and
2023. The Transparency Data used for this analysis were applicable in roughly May 2025.34 Since
the in-network rates were collected in 2025, it is possible that rates differed from those applicable
at the time the disputed service was furnished. Furthermore (and potentially more problematic),
the 2024 IDR outcomes may have influenced the 2025 in-network rates. For example, insurers
and in-network providers could have renegotiated rates as a result of their experiences with the
IDR process. Similarly, IDR outcomes may have affected provider and insurer decisions to
contract with each other and, correspondingly, the in-network rates included (or excluded) in this
analysis.35
Second, the Transparency Data have limitations associated with the Transparency in Coverage
data reporting.36 For example, certain insurers negotiate rates that are a percentage of the
provider’s billed charges, which are displayed in the transparency data as a percentage (and not a
dollar amount). Without the amounts that providers charge, which are not reported under the
Transparency in Coverage requirements, these rates cannot be compared with rates expressed as
dollar amounts. Although this represented a small percentage of total rates, the exclusion of these
rates could affect the results of this analysis in the selection of benchmark median in-network
rates. Similarly, it could affect provider and insurer decisions in regard to the IDR process and in
negotiations outside of the IDR process.
As another example, Transparency Data indicate whether each particular rate applies to an
individual provider, a facility, or both. The Kaiser Family Foundation (KFF) examined
Transparency in Coverage data and found instances where rates in these datasets may seem
unlikely based on the individual provider/facility label.37 In one example, rates for an individual
practitioner were labeled as a facility rate in the Transparency in Coverage data. For purposes of
this report, CRS was unable to use PUF Details File information to identify whether an IDRparticipating provider was going through the IDR process as an individual provider or a facility,38
and therefore could not use such information to verify and/or filter out rates for providers in the
34 The Payerset Transparency Data also do not indicate when a rate started applying, and there is no retention
requirement for the insurer transparency data. See Question #37, CMS, Technical Clarifications, September 10, 2024,
https://web.archive.org/web/20250809221511/https://www.cms.gov/healthplan-price-transparency/resources/technicalclarification. CMS, “In-Network File,” https://github.com/CMSgov/price-transparency-guide/tree/master/schemas/innetwork-rates.
35
For example, a provider that was out-of-network and participating in an IDR dispute that was resolved in the first
half of 2024 could have become in-network with the disputed insurer by 2025. Insurers and providers both have
indicated changes in contracting and network participation after the passage of the No Surprises Act, with several
providers indicating attempts to use IDR outcomes in in-network rate negotiations to varying success. Rasmussen et al.,
Implications of the No Surprises Act, pp. 23-29.
36 For more information, for example, see CRS Report R48570, Technical Challenges with Private Health Insurance
Price Transparency Data.
37 Gary Claxton et al., Challenges with Effective Price Transparency Analyses, Peterson-KFF Health System Tracker,
February 25, 2025, https://www.healthsystemtracker.org/brief/challenges-with-effective-price-transparency-analyses/.
38 As an example, an individual provider that is incorporated can have an NPI for themselves and an NPI for their
corporation.
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Transparency Data that did not have matching provider/facility labels.39 Without this verification
and/or filter, additional rates could be included in this analysis that could affect the calculation of
median in-network rates, since median rates are calculated for each combination of assigned state,
dispute service code, and whether the rate related to an individual provider or a facility. Future
research may be able to address this limitation using a new variable added to 2025 IDR dispute
data that indicates whether a dispute in the PUF Details File was initiated by an individual
provider or initiated by a facility.
Third, the PUF Outcomes File does not include billing code modifiers that may apply to a
disputed service. Billing code modifiers can be attached to a billing code to indicate that the
performance of a medical service has been altered by a specific circumstance but not changed.
For example, a billing code modifier could indicate that a service was provided via telehealth. Innetwork rates can vary by billing code modifier, and if a disputed service in the PUF Outcomes
File had a billing code modifier, this could create discrepancies in the analysis.
Finally, geographic variable differences between the PUF Details File and the PUF Outcomes File
limited the specificity of the analysis. QPAs generally are determined at the MSA level.40 Because
the PUF Details File indicates the state in which the disputed service was provided and is used to
assign in-network rates to states, in-network rate summary statistics do not account for variation
across in-network rates within a state. This could contribute to distinctions between the median
QPA in the PUF Outcomes File and the median in-network rate, particularly if there are states
where disputes are spread across multiple MSAs within a state and such MSAs have large
variations in rates. This may be less consequential in states that have emergency service disputes
that are largely concentrated within one MSA, such as Idaho and Nevada.
Analytical Findings
This section first analyzes—at the multi-state level—how QPAs, insurer and OON provider
offers, and outcomes of selected IDR emergency service disputes resolved in the first half of 2024
relate to the 2025 median in-network emergency service rates of IDR-participating providers.41 It
then discusses the extent to which these outcomes vary at the state level.
The findings are reported as a relative percentage of in network rates. For example, 100% means
the IDR outcome equals the median in-network rate for that particular service in the same state
and as provided by an individual provider or facility. Above 100% means the IDR outcome
exceeds the corresponding median in-network rate. Below 100% means the IDR outcome is lower
than the corresponding median in-network rate.
39 CRS did compare Transparency Data NPI and provider/facility variables to CMS National Plan and Provider
Enumeration System (NPPES) data, which is a database where providers enter information such as name, address,
taxonomy, and NPI type. NPPES NPI type indicates whether a provider has an NPI associated with an individual
provider (i.e., Type 1) or has an NPI associated with a health care organization or facility (i.e., Type 2). CRS used the
NPI variable to link the Transparency Data with NPPES and identified discrepancies similar to those pointed out by the
Kaiser Family Foundation (i.e., instances where the Transparency Data’s provider/facility designation differed from the
NPI type indicated in NPPES). In total, over 75% of negotiated rates used for this analysis that were identified as
applying either to an individual provider or a facility had a Transparency Data provider/facility designation that
matched the NPPES NPI type. Of the rates used in this analysis that did not match provider/facility type between the
Transparency Data and NPPES, it was more common to see Transparency Data facility rates paired with an individual
provider (Type 1) NPPES designation as compared to Transparency Data individual provider rates paired with a health
care organization or facility (Type 2) NPI designation. CRS did not address instances where the Transparency Data did
not match NPPES in this product.
40 See 45 C.F.R. §149.140(a)(7).
41 Disputes resolved in Q1 and Q2 of 2024 can pertain to services provided prior to 2024.
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Aggregate Analysis
Across all 14 states examined, for IDR emergency service disputes resolved in the first half of
2024, the median prevailing offer was over three times the median in-network rate of IDRparticipating providers (312% of median in-network rate) for that service, and over 95% of
disputes had a prevailing offer that was above the median in-network rate (see Figure 1, where
the median in-network rate of IDR-participating providers is depicted by the dotted vertical line at
100%). For these disputes, the median provider offer was similarly above the median in-network
rate (321% of median in-network rate).
Figure 1. Distributions of IDR Emergency Service QPA, Offers, and Outcomes
Relative to Median In-Network Rates
Source: CRS analysis of Payerset Transparency Data for May 2025 and Departments of Health and Human
Services, Labor, and the Treasury, Federal Independent Dispute Resolution (IDR) Public Use File (PUF) for 2024,
Q1, Federal IDR PUF for 2024, Q2.
Notes: Disputes resolved in Q1 and Q2 of 2024 can pertain to services provided prior to 2024. Median innetwork rate is the 2025 median rate for a given service among all providers in the state that participated in an
emergency service dispute that was resolved in the first half of 2024 and has negotiated rates included in
Payerset Transparency Data. It is based on each unique combination of billing code, state, and whether the
provider was an individual provider or a facility. The median in-network rate of IDR-participating providers is
depicted by the dotted vertical line at 100%. In each box plot, the vertical black line represents the median, the
ends of the box represent the 25th percentile and the 75th percentile, and the ends of the tails represent the 1st
percentile and the 99th percentile. IDR = independent dispute resolution. QPA = qualifying payment amount. For
this figure, all values exceeding 1,000% were top-coded at 1,000%.
The total amount of revenue that an OON provider received for care would be less than the
prevailing offer, as the provider would have had to pay an administrative fee to the federal
government to participate in the IDR process, which was $115 per dispute for most of 2024,42 and
42 See 45 C.F.R. §149(d)(2)(ii). The IDR emergency service disputes analyzed include batched disputes. Batched
(continued...)
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a fee to the IDR entity if its offer was not selected.43 For high-level context, the median prevailing
offer among all analyzed emergency service disputes was $627 (and the median QPA among all
analyzed emergency service disputes was $226).44
The median QPA was slightly higher than the median in-network rate (112% of median innetwork rate). Although more times than not, the QPA was also higher than the median innetwork rate of providers participating in the IDR process, the QPA was frequently below the
median in-network rate (roughly 44% of analyzed disputes). Similar to the median QPA, the
median insurer offer was slightly above the median in-network rate (131% of median in-network
rate), which aligns with CMS’s observation that insurers frequently benchmark their offers to the
QPA.
State-Level Analysis
Conducting the same analysis—comparing selected first half 2024 IDR emergency service
dispute QPAs, insurer and provider offers, and prevailing offers relative to the 2025 median innetwork rates of IDR-participating providers—at the state level in 14 states shows distributions
that varied by state (Figure 2).45 For example, in Texas, the state with the largest number of
analyzed disputes (46% of analyzed disputes), the median QPA and the median insurer offer
relative to the median in-network rate of providers in the state (119% and 131%, respectively)
were similar to the corresponding aggregated medians. At the same time, the median provider
offer and the median prevailing offer relative to the median in-network rate of providers in the
state (390% and 386%, respectively) were higher than the corresponding aggregated medians. In
contrast, and relative to the state’s median in-network rate, Nevada had a median QPA (35% of
the state’s median in-network rate), median plan offer (36% of the state’s median in-network
rate), median provider offer (118% of the state’s median in-network rate), and median prevailing
offer (118% of the state’s median in-network rate) lower than the corresponding aggregated
ratios.
For all 14 states in this analysis, the median prevailing offer was above the median in-network
rate of IDR-participating providers, and in nine states it was over three times the median innetwork rate. The degree to which the median prevailing offer exceeded the median in-network
rate, however, varied.46 In Nevada and California, the median prevailing offer was slightly higher
than the median in-network rate (118% and 129% of the state’s median in-network rate,
disputes are disputes in which multiple qualified services are considered jointly as part of one IDR determination. 42
C.F.R. §149.510(a)(2)(i). Parties pay one administrative fee for batched disputes. See also HHS, Department of Labor,
and Department of the Treasury, Federal Independent Dispute Resolution (IDR) Process Guidance for Certified IDR
Entities, December 2023, p. 32, https://www.cms.gov/files/document/federal-idr-guidance-idr-entities-march-2023.pdf.
43 Since provider offers have been frequently selected, plans often were responsible for paying the IDR entity fees. For
most of 2024, the IDR entity fee for a single determination was allowed to range from $200 to $840; for batched
determinations, it was allowed to range from $268 to $1,173. For batched disputes exceeding 25 dispute line items,
IDR entities also were allowed to set a fixed fee within $75-$250 for each additional increment of 25 dispute line items.
Departments of the Treasury, Labor, and HHS, “Federal Independent Dispute Resolution (IDR) Process Administrative
Fee and Certified IDR Entity Fee Ranges,” 88 Federal Register 88494, December 21, 2023.
44 See Appendix B for additional characteristics of IDR dispute sample used for analysis.
45 Dispute prevalence was highly concentrated in Texas, Florida, Arizona, and Nevada, which accounted for 46%, 26%,
12%, and 8% of analyzed disputes, respectively.
46 Research that looked at average emergency service dispute prevailing offers relative to QPA by state also identified
variance between states with respect to these ratios. See supplementary materials for Erin L Duffy et al., “No Surprises
Act Independent Dispute Resolution Outcomes for Emergency Services,” Health Affairs Scholar, vol. 2, no. 11
(November 2024).
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respectively), whereas Colorado saw a median prevailing offer that was over six times the median
in-network rate (619% of the state’s median in-network rate).
There also was variance among states in how their median QPA compared with their median innetwork rates. Six states (Arizona, California, Louisiana, Nevada, Utah, and Washington) had a
median QPA that was less than the median in-network rate of the IDR-participating providers. In
the remaining eight states, the median QPA was above the median in-network rate of the IDRparticipating providers. This means that in these eight states, an OON payment that equaled the
median QPA would represent a higher payment than over a majority of the IDR-participating innetwork rates for the service.
Figure 2. Median IDR Emergency Service QPA, Offers, and Outcomes Relative to
Median In-Network Rates, by State
Source: CRS analysis of Payerset Transparency Data for May 2025 and Departments of Health and Human
Services, Labor, and the Treasury, Federal Independent Dispute Resolution (IDR) Public Use File (PUF) for 2024,
Q1, Federal IDR PUF for 2024, Q2.
Notes: After the “All Disputes” row, states are organized in ascending order of median prevailing offer value.
Disputes resolved in Q1 and Q2 of 2024 can pertain to services provided prior to 2024. Median in-network rate is
the 2025 median rate for a given service among all providers in the state that participated in an emergency
service dispute that was resolved in the first half of 2024 and has negotiated rates included in Payerset
Transparency Data. It is based on each unique combination of billing code, state, and whether the provider was
an individual provider or a facility. The median in-network rate of IDR-participating providers is depicted by the
dotted vertical line at 100%. IDR = independent dispute resolution. QPA = qualifying payment amount.
The median insurer offer relative to the median in-network rate also varied by state. In five states
(Arizona, California, Nevada, Utah, and Washington), the median insurer offer was below the
median in-network rate.47 Of the remaining eight states, four states (Alabama, Michigan,
Louisiana, Colorado) had a median insurer offer that was over two times the median in-network
rate (282%, 247%, 209%, and 208% of the state’s median in-network rate, respectively). Provider
47 In all of these states, the median QPA also was below the median in-network rate.
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win rates were slightly lower in three of these four states; providers won in 85% of Alabama
disputes, 79% of Michigan disputes, 80% of disputes in Louisiana, and 84% of Colorado
disputes, relative to 85% of disputes across all states in this analysis (Table 1). Overall, there was
little/slightly negative correlation between a state’s median insurer offer and provider win rate
(-0.21).
The median insurer offer relative to the median QPA also varied by state, indicating that insurers
operating in different states appear to take different approaches with respect to IDR offers. In all
14 states, the median insurer offer was at or above the median QPA, with five states (Arizona,
Connecticut, Nevada, Utah, and Washington) having no (or minimal) difference between the
median insurer offer and the median QPA. Alabama, Louisiana, and Michigan had the most
separation between the median insurer offer and the median QPA. Overall, there was little/slightly
negative correlation between the size of the difference between median insurer offers and median
QPA in a state and the state’s provider win rate (-0.15).
Some of the state-by-state variation could be due to differences in the types of emergency service
disputes going through the IDR process in a given state. As an example, in most states, the most
common disputed emergency service was for a moderate-level emergency room visit (CPT Code
99284); in Connecticut, Nevada, and Utah, by contrast, the most common disputed billing code
was for a high-level emergency room visit (CPT Code 99285).48 In another example, in 11 states,
facilities accounted for 1% or less of the state’s emergency service disputes, but facilities
accounted for a much higher percentage of state disputes in Texas and Colorado (26% and 38% of
the state’s disputes, respectively).49
Table 1. Percentage of IDR Emergency Service Disputes Where Provider Was the
Prevailing Party, by State
State
Provider Win Percentage
Utah
100%
New Mexico
94.7%
Nevada
93.4%
Washington
90.0%
Florida
89.7%
Arizona
86.2%
48 To compare this to the breakdown of CPT codes across all disputes used for analysis, see Appendix B.
49 The data limitation associated with Transparency Data’s provider/facility designation and how it can differ from the
NPI type indicated in NPPES was more pronounced with respect to Transparency Data facility rates being tied to a
provider with an individual provider (Type 1) NPPES designation. To the extent these differences inappropriately
affected the calculation of median in-network rates for facilities, these effects would be more pronounced in states that
had more disputes involving facilities, such as Colorado and Texas. For context, among the entire universe of Colorado
disputes involving both individual providers and facilities, the median QPA was 139% of the state’s median in-network
rate and the median prevailing offer was 619% of the state’s median in-network rate. Among the Colorado disputes
involving only individual providers, the median QPA was 140% of the state’s median in-network rate, and the median
prevailing offer was of 390% of the state’s median in-network rate. Among the entire universe of Texas disputes
involving both individual providers and facilities, the median QPA was 119% of the state’s median in-network rate and
the median prevailing offer was 385% of the state’s median in-network rate. Among the Texas disputes involving only
individual providers, the median QPA was 98% of the state’s median in-network rate, and the median prevailing offer
was of 306% of the state’s median in-network rate. Of the 11 states where facility disputes accounted for 1% of less
than the state’s emergency disputes, 9 saw no changes in median QPA and median prevailing offer when excluding
facility disputes, and the other two states saw small changes (3% or less) in median QPA and median prevailing offer
when excluding facility disputes.
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State
Provider Win Percentage
Alabama
85.5%
Colorado
83.6%
Texas
81.2%
Louisiana
80.3%
Idaho
78.8%
Michigan
78.6%
California
77.4%
Connecticut
55.3%
Source: CRS analysis of Departments of Health and Human Services, Labor, and the Treasury, Federal
Independent Dispute Resolution (IDR) Public Use File (PUF) for 2024, Q1, Federal IDR PUF for 2024, Q2.
Notes: IDR = independent dispute resolution process.
Summary and Policy Implications
This analysis compares median QPAs, insurer and provider offers, and prevailing offers to the
median in-network emergency service rates of IDR-participating providers in selected states. The
findings indicate several broad patterns. First, over 95% of disputes had a prevailing offer that
was above the median in-network rate among IDR-participating providers. Second, the median
prevailing offer in the IDR process for emergency service was slightly more than three times the
median in-network rate among IDR-participating providers. Third, the median QPA was slightly
higher than the median in-network rate.
An overall median prevailing offer in the IDR process for emergency service that is over three
times the median in-network rate among IDR-participating providers suggests the IDR process
could be used by IDR-participating providers in negotiations with insurers to put upward pressure
on in-network emergency service rates.50 Depending on the extent to which these negotiations
result in increased in-network rates, this could increase health care costs for emergency services.51
Across all states examined, the median prevailing offer was above the median in-network rate of
IDR-participating providers. However, there was substantial state level variation in the median
prevailing offers relative to the median in-network emergency service rates of IDR-participating
providers in the state. For example, Nevada and California had median prevailing offers that were
only modestly higher than their respective state median in-network rates, at 118% and 129% of
the state’s median in-network rate, respectively. By contrast, Colorado had a median prevailing
offer that was more than six times the median in-network rate, at 619% of the median in-network
rate. Overall, 9 of the 14 states analyzed had median prevailing offers that exceeded three times
the state’s median in-network rate.
50 Discussion with interest groups on the No Surprises Act in early 2024 revealed that several providers successfully
used the IDR process in contract negotiations with insurers, but this was not a universal opinion. For more information
on these discussions, including utilization of the QPA in contract negotiations, see Rasmussen et al., Implications of the
No Surprises Act.
51 Other IDR process factors not analyzed also could affect the extent to which IDR outcomes can contribute to
increased emergency service in-network rates, such as the percentage of OON emergency service claims that are
eligible for and reach an IDR process determination and the characteristics and prevalence of the providers using the
IDR process.
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This state level variation implies that the extent to which providers may be able to use IDR
outcomes in contract negotiations with insurers to exert upward pressure on in-network
emergency service rates may differ across markets. In states where prevailing offers closely track
median in-network rates, the negotiation leverage associated with IDR outcomes may be more
limited. In states where prevailing offers diverge substantially from in-network rates, however,
IDR outcomes may be able to play a more pronounced role in shaping contracting behavior and,
potentially, health care spending for emergency services.
Variation also was observed in QPAs relative to median in-network rates. In six states, the median
QPA was less than the median in-network rate of IDR-participating providers; in the other eight
states, the median QPA exceeded the median in-network rate. This variation suggests the QPA
may be perceived differently by OON IDR-participating providers across states. In states where
the QPA falls below the median contracted rate, some OON providers, particularly those with
relatively high negotiated rates with other insurers, may view the QPA as an inadequate
benchmark. Depending on initial OON negotiations with a disputing insurer, providers with high
negotiated rates with non-disputing insurers may be more inclined to pursue the IDR process,
which also may influence which negotiated rates are represented in the analytical sample.
More research on the IDR process, including what percentage and types of OON disputes are
going through the process, could provide indications about the extent to which the IDR process
could be affecting health care costs, including in-network rates; network participation; and, by
extension, the federal budget. In addition, research that looks at OON disputes and IDR
participation by different criteria (e.g., specific geographies, non-emergency OON services,
provider/insurer characteristics) may provide additional, more nuanced insights into how the IDR
process could interact with underlying market dynamics.
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Appendix A. Methods
Payerset Transparency Data
The Congressional Research Service (CRS) used the public-use file (PUF) Details File to identify
the 3,800 providers that were part of a dispute involving emergency services (i.e., involved
service codes 99281, 99282, 99283, 99284, 99285)52 that were provided in an emergency room of
a hospital (i.e., had a place of service code 23); that was not a default determination; and that did
not involve a bundled payment.53 Based on this list, Payerset generated a dataset of all in-network
rates (within the Payerset database) for emergency services codes for the identified set of
providers, which totaled 3.1 million in-network rates.54 The resulting dataset is referred to as
Transparency Data in this report.
CRS trimmed and modified the Transparency Data to better align the data with the types of
disputes that went through the independent dispute resolution (IDR) process in the first half of
2024 and to account for certain challenges associated with the underlying Transparency in
Coverage data requirements.55
First, CRS limited the dataset to include only in-network rates expressed as a dollar amount, a
derived amount, or part of a fee schedule (in instances where the fee schedule had no
corresponding in-network rate or derived amount for the unique combination of payer, National
Provider Identifier [NPI], CPT code, place of service code, and reporting entity name). Rates that
were expressed as a percentage of billed charges, were expressed as per diem rates, or had other
designations were excluded from the analysis.56 Of the initial 3.1 million rates, 55.07% were
negotiated dollar amounts, 31.92% were fee schedule rates (of which, less than 1% had a
corresponding negotiated rate), 2.07% were derived amounts, and 10.94% were expressed as a
percentage of billed charges, per diem rates, and other amounts.
Transparency Data also were trimmed to include only rates associated with services provided in
an emergency room of a hospital (i.e., rates associated with service code 23), as 99.73% of IDR
disputes involving emergency service codes occurred in an emergency room of a hospital.
Because facility rates in the Transparency Data are not required to include service code values,
rates for facilities were not trimmed if no service code was listed and the provider was a
hospital.57 Of the initial 3.1 million rates, 48.42% of rates were for services provided outside of a
hospital emergency room.
52 Emergency department visits are coded based on increasing levels of complexity associated with the visit, with
service code 99281 representing the least complex and service code 99285 representing the most complex.
53 Default determinations occur if one party does not submit an offer or pay their fees, while the other party submits
both an offer and fees. In these instances, the party submitting the offer and fees wins the determination by default. A
bundled payment is where a provider or facility bills multiple items or services under a single service code.
54 Of the 3,800 unique National Provider Identifiers (NPIs) identified, all but roughly 160 NPIs had negotiated rates in
the Payerset database.
55 For more information on these challenges, see CRS Report R48570, Technical Challenges with Private Health
Insurance Price Transparency Data.
56 For more information on the terms negotiated, derived, fee schedule, percentage, and per diem, see technical
documents associated with the Transparency in Coverage data. CMS, “In-Network File,” https://github.com/CMSgov/
price-transparency-guide/tree/master/schemas/in-network-rates.
57 See “service_code” definition at CMS, “In-Network File,” https://github.com/CMSgov/price-transparency-guide/
tree/master/schemas/in-network-rates.
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In addition, Transparency Data were limited to in-network rates that were not part of a bundled
payment or capitated payment amount. Bundled payments are single payments for a combined set
of items and services. Under capitation, a provider is paid a set amount based on the number of
people cared for, regardless of the number of services provided. Of the initial 3.1 million rates,
0.05% of rates were bundled payments and 0.11% were capitated rates.
Also excluded from the Transparency Data were any rates associated with billing modifiers.
Billing modifiers are codes that signify an item or service is provided in altered circumstances
(e.g., only the technical component of a service was provided, or the service was provided via
telehealth) and may cause pricing changes. IDR dispute data do not include information on billing
code modifiers. Of the initial 3.1 million rates, 12.69% of rates were associated with a billing
modifier.
CRS also excluded from the Transparency Data any non-CPT billing code types (e.g., Healthcare
Common Procedural Coding System [HCPCS]), as IDR dispute data associated with service
codes 99281, 99282, 99283, 99284, and 99285 were all CPT codes. Of the initial 3.1 million
rates, 2.83% of rates were indicated as HCPCS.
CRS modified United Healthcare custom emergency service rates within the data. United
Healthcare has custom rates for emergency services that are provided in an institutional setting.
These rates are associated with the “billing_code” values EMR, EMR1, EMR2, EMR3, EMR4,
and EMR5.58 EMR1 through EMR5 were reassigned CPT codes of 99281-99285, respectively,
and EMR was not used. All of United’s EMR codes accounted for 1.72% of the initial 3.1 million
rates.
Duplicate values were identified based on rates that matched according to the following variables:
payer, NPI, Taxpayer Identification Number (TIN), billing class, negotiated rate, negotiated type,
reporting entity name, and reporting entity type. Duplicates were subsequently removed.
After all trimming and modifications, the Transparency Data universe for analysis contained
roughly 740,000 rates relating to over 3,600 providers.
PUF Details File
The PUF Details File was used to match providers (and their in-network rates) to relevant states
in which they provided OON emergency services that were subsequently part of an IDR dispute.
If a provider was identified as having participated in an IDR dispute in the PUF Details File that
pertained to this analysis, the provider was designated as operating within the state in which each
disputed service was provided. In some instances, providers had multiple disputes and different
disputes involved services provided in different states. For example, of the 3,800 unique,
applicable providers in the PUF Details File, 117 participated in disputes spread across two states,
24 participated in disputes spread across three states, 12 participated in disputes spread across
four states, 4 participated in disputes spread across five states, and 1 participated in disputes
spread across six states. In these instances, providers were designated as operating in every state
in which they had at least one relevant dispute.
Once the state(s) of the provider were assigned, this information was joined with the
Transparency Data using the NPI variable.
58 For more information on United Healthcare’s usage of custom codes, see discussion of “Custom Billing Codes” in
Gary Claxton et al., Challenges with Effective Price Transparency Analyses, Peterson-KFF Health System Tracker,
February 25, 2025, https://www.healthsystemtracker.org/brief/challenges-with-effective-price-transparency-analyses/.
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Within the Transparency Data, medians of in-network rates were determined by finding the
median value among the rates for each unique combination of billing code, state, and whether the
rate applied to a provider or a facility. Providers operating in multiple states had their in-network
rates counted in each state that they operated in. Of the roughly 740,000 in-network rates, roughly
445,000 rates applied to over 2,300 providers located in the 14 states included in the analysis.
PUF Outcomes File
The PUF Outcomes File contains information on 578,212 IDR dispute items resolved in the first
half of 2024. This file was trimmed to include only emergency service disputes, which
represented 40.40% of dispute items (or 233,575 disputes). These disputes were further trimmed
to focus on emergency services provided in an emergency room of a hospital, which represented
99.73% of IDR disputes involving emergency services.
Bundled disputes (1.97% of emergency service IDR disputes) also were removed from the
universe, because the offer and payment amounts for these items could represent the payment
amount for a bundle of services.
Furthermore, 22.67% of emergency service disputes had selected data elements suppressed due to
privacy concerns, did not have all data values entered, or had negative qualifying payment
amounts (QPAs).59 In such instances, the disputes were removed from the dataset. Default
determinations also were removed, as these represented disputes where one party did not submit
an offer or pay applicable fees. Of the emergency service disputes, 19.10% were default
determinations (or had no response for this variable).60
The initiating party variable indicates whether a dispute was initiated by an insurer, an individual
provider, or facility. The variable was used as a proxy to determine whether individual provider
rates or facility rates should apply to a given dispute. Disputes initiated by insurers were excluded
from this analysis. Given that individual providers and facilities have been heavy utilizers of the
IDR process and have initiated a majority of disputes, trimming insurer-initiated disputes reduced
0.008% of emergency service dispute items.
After accounting for these adjustments, the PUF Outcomes File had 167,147 dispute items.
Finally, the geographic location in the PUF Outcomes File was modified. The PUF Outcomes File
lists geographies at the metropolitan statistical area (MSA) level, which can span state lines. Each
dispute in the PUF Outcomes File was assigned a state of location that represented either the state
in which the entire MSA was located or a state that contained a portion of the MSA.
59 Dollar amounts are suppressed for services with fewer than 10 line items in a geographic region and quarter. Since
geographical information in the Centers for Medicare & Medicaid Services (CMS) Outcomes File is listed at the
metropolitan statistical area (MSA) level, geographic information may not be reported if occurring outside of an MSA.
Relatively few disputes (0.03% of emergency service disputes) had non-reported geographic information and nonsuppressed information for qualifying payment amounts, insurer offers, provider offers, or prevailing offers. For more
information see CMS, Federal IDR PUF Data Dictionary, at https://www.cms.gov/nosurprises/policies-and-resources/
reports.
60 Given that default determination would occur if a party did not submit an offer, there was substantial overlap
between default determination disputes and disputes that had missing insurer offers and provider offers.
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IDR Emergency Service Outcomes Relative to In-Network Negotiated Rates
Sample Used for Analysis
Only disputes in selected states were used for this analysis in an attempt to reduce potential
distortions of data resulting from different geographic variables between the PUF Details File and
the PUF Outcomes File.
The PUF Details File has disputes at the state level, whereas the PUF Outcomes File has disputes
at the MSA level. Because MSAs can cross state lines, these two files cannot be easily linked by
the geographic variables. As an example, disputes in the PUF Outcomes File that indicate the
service was provided in the Washington-Arlington-Alexandria MSA could be shown in the PUF
Details File as occurring in the District of Columbia, Virginia, Maryland, or West Virginia. To
minimize mis-categorization of states in the PUF Details File (which would create miscategorized in-network rates in the Transparency Data), the analysis was restricted to 14 states
where at least 95% of a state’s trimmed emergency service disputes occurred in an MSA that was
entirely encompassed within that state. For purposes of this calculation, the total number of a
state’s trimmed emergency service disputes included any dispute that occurred in an MSA that
contained at least a portion of the state.61
These 14 states are Alabama, Arizona, California, Colorado, Connecticut, Florida, Idaho,
Louisiana, Michigan, New Mexico, Nevada, Texas, Utah, and Washington. The disputes in these
14 states represented 82,119 disputes, which was about half of the total emergency room disputes
in the trimmed PUF Outcomes File.
Analysis
After the Transparency Data and PUF Outcomes File were prepped, the files were joined so that
median in-network rates were assigned to each dispute item in the PUF Outcomes File based on a
matching state and service code and whether the service was provided by a provider or a facility.
Each dispute item’s QPA, insurer offer, provider offer, and prevailing offer was then presented as
a percentage of the applicable median in-network rate for the same service, in the same state, and
whether provided by a provider or a facility.
61 As an example, there were 291 trimmed emergency service disputes that occurred in MSAs that contained a portion
of Washington state. Specifically, disputes occurred in Bellingham, Kennewick-Richland, Mount Vernon-Anacortes,
Seattle-Tacoma-Bellevue, Yakima, and Portland-Vancouver-Hillsboro. Other than the Portland-Vancouver-Hillsboro
MSA, which contains portions of Oregon and Washington, all other MSAs occur within Washington. All disputes
occurring in these MSAs were used to determine the total number of trimmed emergency service disputes that occurred
in Washington. Roughly 99% of disputes in these MSAs occurred in an MSA that was entirely contained within
Washington, and the remaining roughly 1% occurred in Portland-Vancouver-Hillsboro, which resulted in Washington’s
inclusion for this analysis. Furthermore, the disputes that occurred in Portland-Vancouver-Hillsboro were attributed to
Washington for purposes of the analysis.
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IDR Emergency Service Outcomes Relative to In-Network Negotiated Rates
Appendix B. Selected Characteristics of IDR
Dispute Sample Used for Analysis
Table B-1. IDR Dispute Characteristics
Number of Disputes
Median QPA
Median Prevailing
Offer
82,119
$226
$627
99281
9
$24
$75
99282
149
$82
$548
99283
11,804
$157
$310
99284
43,299
$216
$555
99285
26,858
$260
$781
Alabama
1,327
$159
$525
Arizona
9,454
$173
$507
California
1,174
$190
$450
Colorado
122
$265
$1,099
Connecticut
47
$201
$283
Florida
21,198
$274
$579
Idaho
189
$216
$455
Louisiana
2,349
$150
$742
Michigan
826
$160
$509
New Mexico
431
$167
$724
Nevada
6,697
$167
$458
Texas
37,997
$231
$736
Utah
17
$382
$1,761
Washington
291
$211
$636
Individual Provider
71,573
$203
$578
Facility
10,546
$1,163
$2,526
Characteristic
Total Disputes
CPT Code
State
Individual Provider/Facility
Source: CRS analysis of Departments of Health and Human Services, Labor, and the Treasury, Federal
Independent Dispute Resolution (IDR) Public Use File (PUF) for 2024, Q1, Federal IDR PUF for 2024, Q2.
Notes: IDR = independent dispute resolution process.
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IDR Emergency Service Outcomes Relative to In-Network Negotiated Rates
Author Information
Ryan J. Rosso
Specialist in Health Care Financing
Acknowledgments
Sylvia Bryan, CRS Research Assistant, provided general research support and produced the “Distributions
of IDR Emergency Service QPA, Offers, and Outcomes Relative to Median In-Network Rates” graphic.
Disclaimer
This document was prepared by the Congressional Research Service (CRS). CRS serves as nonpartisan
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Congressional Research Service
R48851 · VERSION 2 · NEW
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