One car-accident patient, followed from the emergency room to federal Independent Dispute Resolution (IDR). It shows why hospitals that accept the plan’s first payment on long, post-emergency stays are leaving most of the money behind.
When a patient can’t safely leave, the No Surprises Act protects every day of the stay, and the hospital can take the underpayment to IDR. On typical hip and femur stays in 2025, the winning offer was about 2.7x what the plan paid.
Hit by another car at an intersection. EMS takes the patient to the nearest emergency department, which is out of network.
The patient’s femur fracture is fixed with a rod that night, and they’re stabilized.
The hospital offers a move to an in-network hospital. The patient can’t bear weight, so the only way to move them is by ambulance.
No new claims. If a valid waiver were possible here, the inpatient days that follow could be billed to the patient instead of the plan.
The patient stays and signs a consent form. It doesn’t count: they could only have left by ambulance, so they couldn’t give valid consent.
The patient goes home. Every day of the stay was protected emergency care under the No Surprises Act.
$33K in plan QPAs against about $94K in typical IDR outcomes, split between the hospital and five physician groups.
Once a patient is stabilized, an out-of-network hospital can sometimes ask them to waive their protections. CMS says that consent isn’t valid if the patient could only leave by ambulance, which is this patient’s situation from step 3 on. The protection therefore covers the four inpatient days as well as the ER visit.
Dollar figures are illustrative estimates based on CMS federal IDR data. Actual awards vary by market, payer and case.
The patient gets no balance bill and pays their normal deductible and coinsurance, as if the hospital were in network.
The plan pays an amount it sets, usually close to its qualifying payment amount (QPA): its median in-network rate.
The rest of the bill is between the hospital and the plan. Most hospitals accept the payment and move on.
CMS walks through almost this exact case in its own consumer guide (a ski accident, leg surgery at an out-of-network hospital, and an invalid waiver).
If 30 business days of open negotiation don’t settle it, either side can file for IDR. Each submits one offer, and a certified arbitrator picks one of the two. The chart below shows 2025 results for hip and femur stays like this patient’s.
A premature or critically ill infant is admitted to a NICU that is out of network with the family’s plan. The baby is stabilized on respiratory support but is too fragile to move. There is no nonmedical transport, and there may be no in-network Level IV NICU nearby.
The stay runs weeks or months, and every day of it is protected post-stabilization care. The longer the stay, the more money is at stake in the dispute.
Same $0 to $100K scale as the chart in chapter 3.
CMS’s consumer guide to the No Surprises Act walks through seven situations. In each one the patient is protected, and the plan’s QPA covers only part of the provider’s bill. The green part of each bar is what’s left for the plan and provider to settle.
A patient with a suspected blood clot goes to an in-network ED. An out-of-network radiologist reads the ultrasound. The patient owes only in-network cost sharing.
The same story as our trauma case: a ski accident, surgery at an out-of-network hospital, and a waiver that is invalid because the patient could only leave by ambulance.
A scheduled surgery at an in-network hospital with an out-of-network assistant surgeon. Assistant surgeons are ancillary, so no waiver can apply.
Same surgery, out-of-network anesthesiologist. Anesthesia is ancillary and always protected.
An emergency helicopter transport after a car accident. The plan must treat it as in network for cost sharing.
A mental health crisis handled at a state-licensed freestanding emergency facility, which counts as an emergency department under the Act.
A state law covers the on-call obstetrician but not the neonatologist. Federal protection fills the gap.
Select a scenario to see what happens in it.
The trauma stay is one example. Read from a hospital’s side, CMS’s guide points to four more places most hospitals never check.
| Number | Where to look | Why it can go to IDR | Source |
|---|---|---|---|
| 1 | Admissions that start in the ED | Care after stabilization counts as emergency care, so the whole stay is protected and it’s paid on a DRG, not a visit fee. | CMS guide, Table 1 |
| 2 | Claims with a signed consent form | A waiver only holds if the patient could leave without an ambulance, an in-network hospital was nearby, and the hospital used CMS’s standard form after a good faith estimate. Many fail at least one. | CMS guide, p. 11 |
| 3 | ER claims denied as “not an emergency” | Plans must judge by the patient’s symptoms on arrival, not solely the final diagnosis, and can’t require prior authorization for emergency care. Overturned denials can go to IDR. | CMS guide, pp. 5 and 24 |
| 4 | Hospital-based groups | Anesthesia, radiology, pathology, neonatology, hospitalists and intensivists can never be waived, and neither can any service with no in-network clinician available on site. | CMS guide, p. 7 |
| 5 | Freestanding EDs, crisis units and air ambulance | State-licensed freestanding and behavioral crisis facilities count as emergency departments. Air ambulance claims generally stay federal even in states with their own law. | CMS guide, pp. 3, 8 and 16 |
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If the patient can only leave by ambulance, the whole stay counts as emergency care, and a signed waiver doesn’t change that.
They pay in-network cost sharing. What’s left of the bill is between the plan and the hospital.
In 2025 the median winning offer on hip and femur stays was about 2.7x the plan’s payment. One NICU claim won 12.3x.
Sources. Trauma and NICU figures: Equavis Health analysis of the CMS Federal IDR public use files, 2025 disputes; the initial payment is used as a proxy for the QPA. The hip and femur figures are medians across DRGs 480 to 482; the NICU figure is a single claim. Patient stories are illustrative composites, not individual patients. Scenarios: CMS, No Surprises Act: Overview of Key Consumer Protections, example scenarios, revised June 2026; dollar figures are CMS’s hypotheticals and summaries are paraphrased. The guide does not have the force and effect of law.
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