Federal IDR guides
What does the IDR entity actually weigh?
The IDR entity must pick one offer. What it must consider, what it cannot, and what 5.4 million 2025 decisions say about how offers play out.
Verified September 11, 2026
Short answer
The IDR entity picks one of the two offers. It cannot split the difference. It must consider the QPA and anything either side submits about the provider's experience, market share, the patient's complexity, teaching status, contracting history, and good-faith efforts. It may not consider billed charges or government rates.
In 2025, IDR entities picked the provider's offer on 86% of decided lines. The winning offer was, at the median, four times the QPA.
Provider win rate
86.4%
Decided lines, 2025
Median winning offer
399%
Of QPA
Payer offered QPA or less
54%
Of decided lines that carry the number
Named IDR entities
15
Win rates from 55% to 96%
The rule
The entity must consider:
- The QPA
- The provider's training, experience, quality, and outcomes
- The provider's or payer's market share in the area
- How sick or complex the patient was
- Whether the provider is a teaching facility, and its case mix and scope of services
- Both sides' good-faith efforts to reach an agreement, and any contracted rates between them in the last four years
The entity may not consider the provider's billed charges, usual and customary charges, or Medicare, Medicaid, or other government program rates.
There is no presumption that the QPA is right. Courts struck that presumption in 2022 and 2023, and the rule no longer contains it.
What the data says
Five things from the 2025 federal IDR public files, covering 5.4 million decided claim lines.
Providers win most of the time. 86.4% of decided lines went to the provider's offer.
Higher asks did not win less often. Providers who asked 150 to 300% of the QPA won 90% of lines. Providers who asked over 1000% of the QPA won 85%, about the same as those who asked under 150%. These are different claims, not the same claim priced two ways, so the table does not say what would happen if you raised one offer.
Payers mostly offer the QPA. The files record the payer's offer against the QPA on 3.8 million of the 5.4 million decided lines. On 54% of those, the payer's offer was at or below the QPA, and providers won 85% of them. The rest do not carry a comparable number either way.
The winning number is usually well above the QPA. Median 399%. A quarter of winning offers were above 813% of the QPA.
Providers file nearly everything. Payers initiated fewer than 400 of 5.7 million lines.
The entity matters
The public files started naming the IDR entity with the release covering the second half of 2025, published in July 2026. Across the fifteen named entities, providers won between 55% and 96% of decided lines. The biggest, Federal Hearings and Appeals Services, decided 783,000 lines and providers won 82% of them. Both sides are meant to agree on the entity, and the other side can object within three business days. If you cannot agree, CMS assigns one at random. And the spread above is what different entities saw, not what you would gain by picking one.
The full entity table for each state is on our state pages.
What this means for a submission
Go through the factors in the entity's order. Give a reason for each one. A number without a reason is just an ask.
The QPA is the payer's number. Show why it does not fit the service, the provider, or the market. Do not argue the payer did the math wrong. That is a different fight.
Do not cite billed charges. The entity cannot use them, and it shows you did not read the rule.
Sources
45 CFR 149.510(c)(4) and (c)(5) as amended August 2026; Texas Medical Association v. HHS (E.D. Tex. 2022, 2023; 5th Cir. 2024); CMS Federal IDR Guidance for Disputing Parties, section 5.4 (entity selection); CMS Federal IDR Public Use Files, 2025 Q1 to Q4, line level, air ambulance excluded, deduplicated to the latest quarterly record. Win rate is provider offer selected over decided lines. Offer-to-QPA comparisons cover only lines where the file records a number. Entity names exist only in the Q3 and Q4 files.
Every number on this page comes from public CMS files or the federal rule. Our methodology explains how we count. Questions? sales@recoursehealth.com
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