How the No Surprises Act applies
Emergency medicine is the clearest No Surprises Act use case. Protected out-of-network emergency services can move into open negotiation and federal IDR when payment is unresolved. The patient protection and the provider payment dispute are separate workflows.
Do not treat every out-of-network claim as an IDR claim. Start with patient protections and routing, then decide whether the public IDR benchmarks support escalation.
High-volume service codes
| Code | Service | Disputes | Provider win rate | Median award | Median award dollars |
|---|---|---|---|---|---|
| 99284 | Emergency department visit for the evaluation and management of a patient, which... | 603,194 | 85% | 4x | $720 |
| 99285 | Emergency department visit, high severity, requiring urgent evaluation | 303,070 | 86.7% | 3.4x | $914 |
| 99283 | Emergency department visit for the evaluation and management of a patient. Modifier... | 215,893 | 81.1% | 4.8x | $1,750 |
| 99282 | Emergency department visit, low to moderate severity | 7,636 | 78.5% | 7x | $1,581 |
| 99281 | 99281 | 928 | 68% | 14.5x | $3,218 |
Top payers
| Payer | Disputes | Provider win rate | Median award |
|---|---|---|---|
| UnitedHealthcare | 278,253 | 85% | 3x |
| BCBSTX | 250,327 | 83.4% | 7.8x |
| Aetna | 137,992 | 88.4% | 3.2x |
| Anthem Blue Cross | 91,941 | 88.9% | 3.5x |
| Cigna / MultiPlan | 90,125 | 77.6% | 4.7x |
| UMR | 50,210 | 83.1% | 3.4x |
| UMR | 45,919 | 90.1% | 2.8x |
| Cigna | 27,435 | 79.9% | 3.6x |
Top states
Operational checklist
- Confirm the visit falls inside the protected emergency-service category.
- Track the initial payment or denial date and open-negotiation window.
- Benchmark ED E/M codes separately; 99284, 99285, and 99283 behave differently.
- Compare payer behavior by state before setting a final offer.
Benchmark your Emergency Medicine claims
IDR Explorer compares your claim mix against CMS Federal IDR outcomes by payer, state, specialty, and service code.
FAQ
Does the No Surprises Act apply to emergency medicine?
Sometimes. Eligibility depends on the service setting, plan type, patient protections, state-law routing, and whether deadlines were preserved.
How many Emergency Medicine federal IDR disputes are in the dataset?
IDR Explorer shows 1,130,093 Emergency Medicine federal IDR disputes in the current benchmark set.
What should emergency medicine teams benchmark first?
Start with payer, state, and service-code mix, then compare QPA multiple, win rate, default rate, and timing against similar disputes.
Related guides
Sources and method
- CMS: Federal IDR reports and public use files
- CMS: About Independent Dispute Resolution
- CMS: Federal IDR timeline for claims
This guide uses CMS Federal IDR public use files through 2025Q4 and is for general information only. Confirm eligibility, deadlines, and state-law routing with current federal guidance, the relevant regulator, and counsel.