Most hospitals that use federal IDR use it for simple ER visits. The bigger money is in admissions that start in the ED, where the No Surprises Act protects the whole stay and the claim is paid on a DRG.
| 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 observation or inpatient 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 you 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-employed groups | Your anesthesia, radiology, pathology, neonatology, hospitalist and intensivist claims can never be waived, and neither can any service with no in-network clinician 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 |
| Have a claim like one of these? Run it through our eligibility check. It takes a couple of minutes and asks for no patient details. Check a claim → | |||
One car-accident admission, step by step: what the law protects at each point, and the claims it creates for the hospital and the physicians.
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.
Read the full case study →When a patient can’t safely leave, every day is protected post-stabilization care, and the plan’s first payment is rarely close to what an arbitrator awards.
Read the full trauma case study →We screen your out-of-network claims, run open negotiation, and take eligible disputes through IDR to payment.
Learn more →Rate benchmarking and negotiation support, including what going out of network with a plan is actually worth.
Learn more →Find where revenue leaks and cost hides, quantified with actuarial rigor and ranked by impact.
Learn more →Claims and remittance files are enough to size the opportunity. We ask for the rest only for claims we plan to file. We sign a business associate agreement before any claim data is shared.
Yes, when the stay began with an emergency visit and the hospital is out of network with the patient’s commercial plan. The No Surprises Act treats post-stabilization care, including observation and inpatient stays connected to the emergency visit, as emergency services, subject to the usual eligibility tests.
Only if the waiver is valid, and many aren’t. After stabilization, a waiver requires that the patient could travel without an ambulance to an available in-network facility nearby, could give informed consent, and signed CMS’s standard form after a good faith estimate. If any condition fails, the claim stays protected and payable by the plan.
No. When the Act applies, the patient pays in-network cost sharing, and CMS states a plan may not raise the patient’s share based on an IDR determination. The dispute is between the hospital and the plan.
No. Federal IDR covers commercial employer, individual and FEHB plans. Medicare (including Medicare Advantage), Medicaid, CHIP, TRICARE, VA and IHS claims are excluded, so we screen them out first.
Based on the CMS No Surprises Act guidance and 45 CFR Part 149. Educational, not legal advice. Equavis Health isn’t a certified IDR entity.
Send us a year of out-of-network claims and we’ll size the opportunity across all five categories before you commit to anything.