Vein & vascularProvider prevailed
Endovenous ablation
36475
220×the plan's initial payment
Out-of-network and underpaid? Federal IDR exists for exactly this.
The No Surprises Act protects patients from surprise bills and gives providers a formal process to challenge out-of-network payments. Ascendix prepares, files and follows every eligible dispute through to payment.
2,000+ IDR disputes managed96%+ win rate on decided disputes$78M+ won since 2023
Case results
2,000+ disputes. 96%+ won. $78M+ recovered for providers.
Out-of-network claims are routinely paid a few hundred dollars. Below are selected determinations from our portfolio showing what the plan paid first and what the certified IDR entity awarded after our team built the case.
2,000+federal IDR disputes managedJanuary 2023 to present
96%+win rate on decided disputesacross payers and IDR entities
$78M+won for providers through IDRsince the start of 2023
12certified IDR entities argued beforeincluding C2C, Capitol Bridge and Maximus
Interventional painProvider prevailed
Lumbar epidural & nerve blocks
644836448464450
186×the plan's initial payment
Spine surgeryProvider prevailed
Two-level lumbar discectomy
6303063035
61×the plan's initial payment
Vein & vascularProvider prevailed
Endovenous ablation
36475
66×the plan's initial payment
Spine surgeryProvider prevailed
Thoracic spine reconstruction
2284322853630466304822610226146308522327
30×the plan's initial payment
Interventional spineProvider prevailed
Lumbar decompression & trigger points
630566305720553
27×the plan's initial payment
Interventional painProvider prevailed
Spinal nerve & facet ablation
647726463564636
19×the plan's initial payment
NeurosurgeryProvider prevailed
Craniectomy for hematoma
61315
17×the plan's initial payment
See the 22 line items behind these examples
| Specialty | CPT | Service | Setting | Initially paid | IDR award | Increase |
|---|---|---|---|---|---|---|
| Vein & vascular | 36475 | Endovenous radiofrequency ablation, first vein | Ambulatory surgery center | $285.62 | $62,699 | 220× |
| Interventional pain | 64483 | Transforaminal epidural injection, lumbar | Ambulatory surgery center | $179.04 | $16,860 | 94× |
| Interventional pain | 64484 | Transforaminal epidural, each additional level | Ambulatory surgery center | $80.41 | $12,736.50 | 158× |
| Interventional pain | 64450 | Peripheral nerve block | Ambulatory surgery center | $33.19 | $24,768 | 746× |
| Spine surgery | 63030 | Laminotomy & discectomy, lumbar, one interspace | Outpatient hospital | $1,574.91 | $77,000 | 49× |
| Spine surgery | 63035 | Each additional interspace | Outpatient hospital | $393.64 | $44,000 | 112× |
| Vein & vascular | 36475 | Endovenous radiofrequency ablation, first vein | Ambulatory surgery center | $694.49 | $46,000 | 66× |
| Spine surgery | 22843 | Posterior segmental instrumentation, 7–12 segments | Hospital emergency department | $989.69 | $19,000 | 19× |
| Spine surgery | 22853 | Interbody biomechanical device | Hospital emergency department | $1,282.40 | $85,000 | 66× |
| Spine surgery | 63046 | Laminectomy, thoracic | Hospital emergency department | $742.95 | $37,000 | 50× |
| Spine surgery | 63048 | Laminectomy, each additional segment | Hospital emergency department | $519.22 | $40,000 | 77× |
| Spine surgery | 22610 | Posterior arthrodesis, thoracic | Hospital emergency department | $774.66 | $27,027 | 35× |
| Spine surgery | 22614 | Arthrodesis, each additional segment | Hospital emergency department | $1,906.08 | $43,222.63 | 23× |
| Spine surgery | 63085 | Vertebral corpectomy, thoracic | Hospital emergency department | $2,320.05 | $12,000 | 5.2× |
| Spine surgery | 22327 | Open treatment, thoracic vertebral fracture | Hospital emergency department | $911.91 | $17,000 | 19× |
| Interventional spine | 63056 | Transpedicular decompression, lumbar | Ambulatory surgery center | $2,565.86 | $73,000 | 28× |
| Interventional spine | 63057 | Decompression, each additional segment | Ambulatory surgery center | $541.26 | $10,400 | 19× |
| Interventional spine | 20553 | Trigger point injections, 3+ muscles | Ambulatory surgery center | $30.53 | $1,850 | 61× |
| Interventional pain | 64772 | Transection or avulsion of spinal nerve | Ambulatory surgery center | $1,643.68 | $40,500 | 25× |
| Interventional pain | 64635 | Facet radiofrequency ablation, lumbar | Ambulatory surgery center | $719.88 | $6,800 | 9.4× |
| Interventional pain | 64636 | Facet ablation, each additional level | Ambulatory surgery center | $364.07 | $4,000 | 11× |
| Neurosurgery | 61315 | Craniectomy, evacuation of intracerebellar hematoma | Inpatient hospital | $2,226.94 | $38,127 | 17× |
Portfolio figures are Ascendix's own records for federal IDR disputes managed from January 2023 to the present. The examples are selected, de-identified determinations from that portfolio; patient, claim and practice identifiers are removed. An IDR award is the out-of-network rate set by a certified IDR entity; the plan then pays that amount less its initial payment and the patient's cost sharing. Past results do not guarantee future outcomes, and every dispute depends on its own facts and documentation.
What federal IDR is
A neutral decides the payment. You only get one shot at the offer.
Since January 2022, the No Surprises Act has limited what patients pay for certain out-of-network care. The difference between what the plan pays and what the service is worth is now settled between the provider and the plan.
When open negotiation fails, a certified IDR entity reviews both sides and selects one party's final offer. There is no splitting the difference, so the quality of the offer packet decides the outcome. The non-prevailing party pays the IDR entity's fee, and both parties pay a federal administrative fee.
Many disputes fail for procedural reasons: a missed business-day deadline, a claim that was never eligible, or a batch that should not have been batched. That is the work we take off your hands.
Which claims qualify
Three kinds of care fall under the federal process.
Emergency services
Out-of-network emergency care at a hospital emergency department or independent freestanding emergency department, including certain post-stabilization services.
OON providers at in-network facilities
Non-emergency services by out-of-network providers at in-network hospitals, hospital outpatient departments, critical access hospitals and ambulatory surgical centers. Think anesthesia, radiology, pathology, assistant surgeons, hospitalists and neonatology.
Air ambulance
Out-of-network air ambulance services billed to group health plans and health insurance issuers.
Usually federal IDR
Self-funded (ERISA) employer plans
- Plans not regulated by state insurance law
- Fully insured plans in states without a specified surprise-billing law for that service
- Federal Employees Health Benefits plans
Usually the state process instead
Fully insured, state-regulated plans
- When a specified state law sets the payment method for that service
- Self-funded plans that have opted in to a state process where the state allows it
- See the State arbitration page
Medicare, Medicaid and other government programs have their own payment rules and are not part of the federal IDR process. Uninsured and self-pay patients use a separate patient-provider dispute resolution process tied to Good Faith Estimates.
The timeline
Eight steps, each with its own clock.
Select a step to see what the rules require and what Ascendix does at that point. Timeframes reflect the federal rules as generally applied; the Departments update guidance and operations from time to time, and we work to the current version.
What Ascendix does
What we handle
From the first remittance to the final payment.
Eligibility screening
We review plan type, service, location, dates and any state law before anything is filed, so fees are not spent on disputes likely to be found ineligible.
Deadline control
Every dispute is tracked in business days from the remittance date. Open negotiation notices, initiations and offers go out inside the window.
Batching strategy
Where federal batching rules allow, similar items and services against the same plan move together, which can reduce cost per claim.
Offer packets
We assemble the supporting information the IDR entity may consider, with clear rationale for the amount you are asking for.
Negotiation
Many disputes settle in open negotiation. We negotiate on your behalf and bring every offer to you before accepting.
Award follow-through
Determinations are tracked to payment. Late or short payments get followed up, and results feed your A/R reporting.
What we will ask you for
Through a secure channel after onboarding, never through this website.
- Claim and remittance data (835 or EOB) showing initial payment date and QPA
- Itemized claim details: CPT/HCPCS, modifiers, units, place of service
- Facility network status and service location
- Provider credentials and specialty
- Your usual charges and any prior contract history with the plan
- Clinical complexity notes where relevant to the offer
Request an eligibility review
Have out-of-network claims paid below value?
Tell us about your practice and the claims you are seeing. We will review whether they fit federal IDR, a state process, or a different route such as appeal or negotiation.
- No cost for the initial review
- Plain answer on eligibility before any fees are paid
- Works alongside your existing billing team if you have one
Ascendix is not a law firm and does not provide legal advice. Eligibility and outcomes depend on applicable laws, regulations, plan type and individual claim circumstances. No outcome is guaranteed.