A data-driven look at IDR offer strategy under the No Surprises Act, why the long-standing 1:1 offer-to-QPA playbook is losing ground, based on the 2023 CMS dispute data, and how payers should adapt.
The No Surprises Act was enacted to protect patients from surprise medical bills: the charges that show up when care at an in-network facility involves an out-of-network provider. To resolve the resulting payment disputes between providers and insurers, the law created the federal Independent Dispute Resolution (IDR) process: a baseball-style arbitration that settles on a payment amount, benchmarked against the Qualifying Payment Amount (QPA), the median in-network rate for a service in a given region.
For plans and issuers, the practical question is deceptively simple: what should you offer? Get it right and you win more disputes at defensible rates. The data suggests the long-standing answer is changing.
CMS has published the 2023 IDR dispute data, and analyzing it produces a counterintuitive result. Historically, offers anchored at roughly 1.0× the QPA produced the most favorable outcomes for payers, an offer in line with the QPA read as reasonable and fair to arbitrators, and tended to win. That conventional 1:1 strategy is now losing effectiveness. The win rate for offers anchored at the QPA has been declining, and the trend is most pronounced in Q4, a strong signal that arbitrators are weighing more than the QPA alone.
The shift indicates arbitrators are increasingly factoring in considerations beyond the benchmark: provider expertise, regional market conditions, and the complexity of the care in question. A defensible QPA is still the baseline, but it’s no longer the whole game.
Two moves follow directly from the data:
Reassess offer anchoring. Stop defaulting to a 1:1 offer-to-QPA ratio. Tailor offers to the additional factors arbitrators now consider: provider expertise, regional market dynamics, and patient complexity.
Strengthen QPA calculations. Use comprehensive, current market data to produce accurate and defensible QPAs, and review them regularly so they reflect prevailing market trends rather than stale inputs.
The broader point is that IDR is now a data problem as much as a regulatory one. The optimal offer ratio is a moving target; the payers who win consistently are the ones continuously testing where it’s landing and adapting as new data and regulatory changes emerge. As the 2024 data is released, refining these strategies will matter even more.
This is the analytical thinking behind our end-to-end IDR solution for payers. If your team is managing IDR at volume, let’s talk.
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