IDR win rates and award amounts.What surgical practices actually recover.

The published data favors providers. Analysis of CMS figures through mid 2025 found providers prevailing in roughly 88 percent of resolved disputes. The American College of Radiology reported the same direction in its review: disputes were decided in the provider's favor in the vast majority of cases.

Win rate is not a guarantee on any single claim. It reflects the pattern across a large body of determinations, and it rewards submissions that pair a credible offer with evidence an arbitrator can act on. A weak submission can lose a winnable claim.

The qualifying payment amount, or QPA, is the plan's median contracted rate for the service, and it is the number plans lean on. In practice, arbitrators award above it most of the time. Reviews of the data found that the prevailing offer exceeded the QPA in roughly 87 percent of determinations, with a median award several times the in network rate.

That gap is the core of the opportunity. When a plan pays at or near the QPA on an out of network claim, the difference between that payment and a well supported IDR award is the revenue a practice leaves behind by not filing.

Recovery depends on the service, the geography, the strength of the submission, and the gap between what the plan paid and the defensible market rate. There is no flat figure, and any honest answer is a range tied to your own claims.

The reliable way to size it is to review a sample of denied or underpaid out of network explanations of benefits, identify the codes, and compare the plan's payment to comparable prior determinations for those codes. That comparison turns an abstract win rate into a dollar figure for your practice.

The IDRE issues a written determination that selects one offer and explains the basis. There is no appeal of the merits. The decision stands, which is why the quality of the submission matters so much going in.

When the provider's offer prevails, the plan owes the difference between what it already paid and the determined amount.

The plan is generally required to pay the determined amount within 30 calendar days of the determination. Most do. When a plan does not, the determination is enforceable, and the provider has recourse to pursue payment.

Track the payment date the same way you track filing deadlines. An award that is won but not collected is not recovery. Following determinations through to payment is part of running IDR well.

Only a small share of eligible claims ever reach arbitration. Estimates of CMS data suggest roughly 10 percent of eligible claims are taken to IDR. The rest are written off, often because preparing a submission by hand is slow and the volume looks unmanageable.

Given the win rate and the typical gap above the QPA, the claims that never get filed represent real, recoverable revenue. The constraint is rarely whether the claims would win. It is whether a team has a fast enough way to file them.