A response to the $22 billion IDR cost headline
This Georgetown report presents a troublingly one-sided picture of the federal IDR process. It focuses heavily on the size of provider awards and provider success rates while giving far too little attention to the conduct of the health plans and the reliability of the data being used to reach its conclusions.
Importantly, Ed Gaines, a healthcare attorney and longtime advocate on reimbursement and No Surprises Act issues, has raised several significant concerns regarding the report's conclusions and its interpretation of the 2025 CMS Public Use File (“PUF”) data. His analysis highlights important context that, in our view, warrants consideration before accepting the report's conclusions at face value.
A closer look at the 2025 CMS data tells a very different story.
Reported award errors require meaningful attention
To start, as Gaines has pointed out, more than $2.5 billion attributed to IDR awards in the 2025 data appears to be associated with obvious data-entry or award errors. These are not minor discrepancies. There is a mechanism for reopening and correcting these awards, and that process is already taking place.
Including those amounts in overall award figures without adequately accounting for the errors creates an inflated and potentially misleading picture of what providers actually received through IDR.
The report gives too little weight to health-plan conduct
The report also fails to give sufficient weight to the health plans' own conduct during the IDR process.
- As further identified by Gaines, more than one-third of the 2025 awards resulted from health plans failing to submit an offer at all and therefore losing by default.
- In another significant percentage of disputes—more than 9.5%—the health plan submitted an offer of $1.00 or less.
That is important context. If the argument is that IDR is creating excessive costs for employers and health plans, then there needs to be an honest discussion about how much of that alleged cost is attributable to the plans' own failure to meaningfully participate in the process.
The QPA comparison deserves serious scrutiny
The reliance on QPA data is equally problematic. If Georgetown's assertion that more than $15 billion in awards exceeded median in-network rates is based upon the QPA figures contained in the 2025 PUF data, then the comparison itself deserves serious scrutiny.
The Fifth Circuit recently invalidated key parts of the federal rules governing the calculation of the QPA. Those rules directly affected the methodology used to generate the QPAs reflected in the 2025 data. That is not a technical footnote. It goes directly to the reliability of the benchmark.
The calculation methodology permitted practices that could artificially suppress the QPA, including the use of so-called “ghost rates,” while failing to properly account for certain incentive and bonus payments. If the methodology used to establish the benchmark was legally defective, then comparing IDR awards against that benchmark and declaring the difference “excessive” is inherently misleading.
Read our separate analysis of what the Fifth Circuit's QPA ruling means for healthcare providers.
The statistics tell a different story when viewed together
Gaines's analysis puts these statistics into context: More than 84% of the IDR cases fall into categories where the health plan either defaulted, offered $1.00 or less, or submitted an offer at or below the QPA.
Yet the report emphasizes that providers prevail approximately 85% of the time as though that statistic, standing alone, demonstrates a problem with the IDR system.
It may demonstrate something entirely different. When a health plan fails to participate, submits a nominal offer, or anchors its position to a QPA calculated under a methodology that has now been invalidated in important respects, a high provider win rate should hardly be surprising.
Why are providers being forced to use IDR?
The same analysis applies to the substantial increase in IDR filings during 2025. Rather than simply pointing to increased utilization as evidence that providers are abusing the process, the more important question is why providers are increasingly being forced to use IDR in the first place.
If plans were consistently making reasonable initial payments and meaningful IDR offers, would we be seeing the same volume of disputes?
That question deserves serious consideration.
A meaningful evaluation must examine both sides of the process
A meaningful evaluation of the federal IDR system cannot focus almost exclusively on provider awards while ignoring plan defaults, nominal offers, questionable QPA calculations, and the methodology underlying the supposed “median in-network” benchmark.
The statistics and observations concerning plan defaults, nominal offers, erroneous awards, QPA calculations, and the combined percentage of disputes discussed above draw upon analysis and commentary by healthcare attorney Ed Gaines regarding the 2025 CMS IDR PUF data.
Why the initial QPA-based offer may persist
Jeffrey Halkovich has described how the original QPA-based payment often remains the plan's position throughout open negotiation. That experience helps explain why the initial payment, plan offer, and negotiation record matter when evaluating IDR volume and outcomes.
Frequently asked questions
Why does Halkovich Law question the Georgetown report's conclusions?
Why do health-plan defaults and nominal offers matter?
Why does the QPA benchmark require scrutiny?
Sources and scope
General information, not legal advice. The disputed statistics identified above are attributed to Ed Gaines's analysis and commentary. This article provides Halkovich Law's general perspective on public materials and does not establish the facts or legal outcome of any individual claim, payer, provider, or dispute.