he No Surprises Act (NSA) created a pathway for providers to challenge insurer underpayments through Independent Dispute Resolution (IDR). For physician groups, facilities, and other providers facing downward pressure on reimbursement, combining an out-of-network (OON) strategy with IDR can deliver financial upside and strategic independence.
Key Benefits of Pursuing the IDR Route
- Higher Reimbursement Rates
IDR often results in significantly higher payments compared to in-network contracted rates. In 2024, providers prevailed in 85% of IDR rulings (CMS, 2025). - Greater Negotiation Leverage
Going OON gives practices leverage in payer negotiations – insurers know IDR may ultimately award providers more than their initial offers. - Fair Market Compensation
IDR rulings are designed to reflect actual service costs and prevailing market rates rather than insurer-imposed benchmarks. - Avoiding Unfavorable Contracts
Providers can maintain independence and avoid long-term, restrictive network agreements that may not reflect today’s market realities. - Proven Success Trends
IDR outcomes continue to favor providers. However, strict compliance with eligibility and documentation rules is essential: more than 30% of IDR cases were dismissed in 2024 due to errors or ineligible filings (GAO, 2024).
Considerations for an Out-of-Network Strategy
Moving OON is not a one-size-fits-all decision. It requires careful planning and compliance safeguards:
- Consultation & Legal Review
Work with counsel or a consultant to confirm that current contracts allow OON participation. - Facility Agreements & Compliance
- Review contracts to ensure no ongoing obligations require staying in-network.
- Ensure providers and facilities deliver clear patient disclosures about OON status.
- Keep disclosures compliant to mitigate risk and maintain patient trust.
- Financial Incentives for Facilities
If currently receiving a stipend, going OON may reduce or eliminate it. This creates motivation for facilities to revisit agreements or restructure contracts.
The Risks of a Poorly Managed IDR Strategy
Some billing agents treat IDR like a “free-for-all,” filing every possible claim without proper vetting. This exposes providers to:
- Dismissals (30%+ of cases, GAO 2024)
- Legal exposure (multiple lawsuits now pending between payers and providers)
- Compliance audits (CMS has signaled increased scrutiny for 2025)
Three Critical Questions to Ask Any Billing Partner or Vendor
- Are you submitting only eligible claims to IDR?
- Can you prove that good-faith negotiation occurred before filing?
- Do you maintain a third-party audit trail of all IDR submissions?
Why BillWell?
At BillWell, we do things differently – with integrity, transparency, and compliance at the core.