Author: Michael Condon, Senior Vice President & GM at AMPS
The IDR Math Nobody Budgeted For
Ask any health plan or TPA running out-of-network claims through the No Surprises Act process what the hardest part is, and you'll get the same answer in different words: it's not the law itself, it's what happens to a single claim once it's inside the process.
A recent roundtable of payers and independent benefits consultants at HPRI made the pattern impossible to ignore. Across different organizations, the same three problems kept surfacing, and none of them are going away on their own.
1. The claim gets handled in pieces, by people who don't talk to each other
At most plans, Payment Integrity owns one slice of an OON claim's life. Operations own the dispute itself. Government affairs are off writing policy letters about the same underlying problem. Each team is doing real work, but no one is looking at the claim end-to-end, and that's exactly the gap that lets the worst billing through.
The fix isn't a fourth team. It's a defensible pricing methodology applied before a claim becomes a dispute, so the people handling it later aren't reconstructing a story that should have been settled at the first payment.
2. Ancillary billing has stopped making sense
The examples payers shared were strikingly consistent: an assistant surgeon billed for more than the primary surgeon and the facility combined. Remote neuromonitoring services billed as though they were performing the procedure. High-acuity ER codes applied to patients who were treated and released the same day.
None of this is really a coding problem. It's a bet that a generic dispute brief, along with a generic settlement offer, won't push back hard enough to matter. And for years, that bet has paid off.
It stops paying off the moment the offer reflects what the role actually is. One payer described rebuilding its assistant-surgeon dispute brief around a simple, factual description of the job: prep, instrument-passing, closing, and post-op monitoring. The payer then priced the offer accordingly instead of defaulting to whatever the primary surgeon's fee happened to be. The result was an IDR win rate that moved from roughly 11% to over 40% on the same claim category, with no change in the underlying claims.
That's not a legal argument. It's a pricing argument, made claim by claim, provider by provider.
3. Winning arbitration was never the real goal
Participants converged on the same conclusion, even though none of them planned to: the win isn't a favorable IDR ruling.
That's the philosophy behind a pricing-first approach to OON claims: price the claim defensibly from the start, negotiate if arbitration becomes necessary, and reserve IDR for the cases that genuinely require it.
None of that comes from automation or a generic formula. It comes from pricing that's built per claim, per provider, and per plan, handcrafted enough to hold up and defensible enough that the other side has less incentive to escalate.
Regulation will take years. Your next claim won't wait.
Every plan in that room wants regulatory reform: a simpler standard, less arbitrage, and less arbitrariness in outcomes. That's a multi-year fight, and it should be fought. But the claims keep coming in the meantime, and the plans absorbing six- and seven-figure awards can't put those payments on hold until Congress acts.
The organizations doing best right now aren't waiting. They're treating OON pricing as a strategy, not a compliance workflow and building the kind of leverage that keeps most claims out of arbitration altogether.
About AMPS
Advanced Medical Pricing Solutions (AMPS) helps health plans and TPAs take control of out-of-network claim exposure before it turns into a dispute. Through PriceDynamix, AMPS applies a defensible pricing methodology to every OON claim. That pricing is built by hand for each claim, provider, and plan, so the first payment holds up and the other side has little reason to escalate. The results are what leverage looks like in practice:
- 97% of disputes are resolved without going to IDR arbitration.
- AMPS wins 80% of the time when arbitration does happen.
- For one large commercial health plan, only 1 in 5,000 NSA-eligible claims has reached IDR.
Health plans and TPAs don't need another compliance workflow. They need leverage. Let's talk about what your OON claim exposure is really costing you. www.AMPS.com