Federal IDR outcomes in California
In 2025 Q1–Q4, the provider or facility offer prevailed in 88.5% of 209,808 determined Federal IDR dispute line items for services provided in California. The median prevailing offer was 2.63x the QPA (25th–75th percentile 1.78x–5.56x; n = 146,356). The median time to a decision was 36 business days (n = 209,808).
Determined line items
209,808
2025 Q1–Q4 · 196 split decisions excluded
Provider win rate
88.5%
n = 209,808 · 2025 Q1–Q4
Median payment vs QPA
2.63x
middle half 1.78x–5.56x · n = 146,356 · 2025 Q1–Q4
Median days to decision
36
business days, from dispute initiation · n = 209,808 · 2025 Q1–Q4
Dollar amounts
Total awarded
$456.0M
sum of prevailing offers · n = 119,246 · 2025 Q1–Q4
Total QPA
$84.6M
sum of QPAs, same line items · n = 119,246 · 2025 Q1–Q4
Awarded above QPA
$371.5M
total awarded minus total QPA · n = 119,246 · 2025 Q1–Q4
Median award per line item
$569
mean $3,824 · n = 119,246 · 2025 Q1–Q4
Median QPA
$183
per line item · n = 119,246 · 2025 Q1–Q4
Award vs QPA, dollar-weighted
5.39x
total awarded ÷ total QPA · n = 119,246 · 2025 Q1–Q4
Dollar amounts come from the separate CMS “QPA and Offers” file: line items decided for the provider or the plan with a non-suppressed QPA and prevailing offer. That file cannot be joined to the line items above, so its n differs. Awarded = the prevailing (selected) offer; it is not a record of what was paid. State comes from the file’s geographic region; a metro area that spans states counts in each. How the dollar figures work
Dollar amounts by period
| Period | Line items with $ | Total awarded | Total QPA | Above QPA | Median award | Median QPA | Award ×QPA ($-weighted) |
|---|---|---|---|---|---|---|---|
| 2025 Q1–Q4 | 119,246 | $456.0M | $84.6M | $371.5M | $569 | $183 | 5.39x |
| 2024 Q3–Q4 | 12,248 | $51.0M | $24.5M | $26.5M | $554 | $193 | 2.08x |
| 2024 Q3–2025 Q4 | 131,494 | $507.1M | $109.1M | $398.0M | $567 | $184 | 4.65x |
| 2023 Q1–2024 Q2 | Not available (see methodology). | ||||||
From the CMS QPA and Offers file (see above). Award ×QPA here is total awarded ÷ total QPA, so large claims weigh more than in the per-line median ratio.
By period
| Period | Line items | Win % | Median ×QPA | 25th–75th | Ratio n | Median days |
|---|---|---|---|---|---|---|
| 2025 Q1–Q4 | 209,808 | 88.5% | 2.63x | 1.78x–5.56x | 146,356 | 36 |
| 2024 Q1–Q4 | 41,131 | 86.9% | 2.48x | 1.44x–5.24x | 25,504 | 50 |
| 2023 Q1–Q4 | 2,406 | 76.2% | 2.00x | 1.26x–3.23x | 1,934 | 49 |
| 2023 Q1–2025 Q4 | 253,345 | 88.2% | 2.60x | 1.74x–5.51x | 173,794 | not pooled |
Line items = determined dispute line items (n). Win rate excludes split decisions and includes default decisions. Ratio n = line items reporting a payment-to-QPA ratio. Days are business days as reported by CMS (2023–2024: from IDR entity assignment; 2025: from initiation) and are never pooled.
By specialty in California
| Specialty group | Line items | Win % | Median ×QPA | Ratio n | Median days |
|---|---|---|---|---|---|
| Hospitals and facilities | 111,748 | 89.6% | 2.07x | 59,072 | 44 |
| Emergency medicine and emergency departments | 57,846 | 89.9% | 2.64x | 52,857 | 30 |
| Internal and family medicine | 6,127 | 87.0% | 6.23x | 6,100 | 27 |
| Not reported / unspecified | 5,893 | 65.8% | 1.25x | 1,415 | 23 |
| Intraoperative neuromonitoring | 4,935 | 87.5% | 17.12x | 4,320 | 36 |
| Neurosurgery and spine surgery | 4,302 | 85.8% | 56.67x † | 4,216 | 28 |
| General and other surgery | 3,536 | 87.6% | 36.83x † | 3,505 | 29 |
| Obstetrics and gynecology | 2,435 | 92.3% | 45.34x † | 2,388 | 27 |
| Anesthesiology | 2,209 | 81.2% | 3.94x | 2,113 | 24 |
| Vascular surgery | 1,929 | 87.9% | 64.95x † | 1,924 | 25 |
| Hospital medicine (hospitalists) | 1,660 | 88.1% | 1.86x | 1,635 | 34 |
| Plastic and reconstructive surgery | 1,534 | 87.4% | 36.46x † | 1,403 | 28 |
| Orthopedic surgery | 1,418 | 87.2% | 44.68x † | 1,215 | 27 |
| Gastroenterology | 984 | 89.7% | 54.37x † | 984 | 27 |
| Other / unclassified labels | 763 | 86.9% | 20.77x † | 742 | 26 |
| Psychiatry | 518 | 70.3% | 1.55x | 509 | 31 |
| Neurology | 481 | 85.2% | 48.39x † | 481 | 30 |
| Urology | 457 | 88.2% | 51.70x † | 451 | 26 |
| Laboratory and pathology | 456 | 75.9% | 6.14x | 454 | 25 |
| Cardiothoracic and thoracic surgery | 178 | 88.2% | 42.02x † | 177 | 27 |
| Radiology | 137 | 78.1% | 120.30x † | 136 | 22 |
| Surgical assistant services | 137 | 79.6% | 57.42x † | 134 | 20 |
| Podiatry | 53 | 90.6% | 48.58x † | 53 | 23 |
| Cardiology | 35 | 68.6% | 511.70x † | 35 | 19 |
| Pain medicine | 34 | 76.5% | 28.81x † | 34 | 25 |
2025 Q1–Q4 · rows with n ≥ 30 determined line items · sorted by n.
Most disputed CPT codes in California
| CPT code | Line items | Win % | Median ×QPA | Ratio n | Median days |
|---|---|---|---|---|---|
| 99284 Emergency department visit with moderate level of medical decision making | 27,810 | 90.6% | 2.55x | 25,782 | 31 |
| 99285 Emergency department visit with high level of medical decision making | 26,513 | 88.9% | 2.36x | 24,563 | 31 |
| 85025 Complete blood cell count (red cells, white blood cell, platelets), automated te | 6,611 | 87.8% | 2.16x | 3,212 | 43 |
| 36415 Insertion of needle into vein for collection of blood sample | 6,244 | 90.2% | 2.22x | 2,763 | 42 |
| 99283 Emergency department visit with low level of medical decision making | 5,183 | 90.3% | 2.86x | 4,523 | 31 |
| 99291 Critical care, first 30-74 minutes | 4,096 | 87.7% | 2.66x | 3,880 | 30 |
| 80048 Blood test, basic group of blood chemicals (Calcium, total) | 3,817 | 87.5% | 2.08x | 1,878 | 39 |
| 93005 Routine electrocardiogram (ECG) using at least 12 leads with tracing | 3,606 | 90.5% | 2.00x | 1,772 | 43 |
| 84484 Troponin (protein) analysis, quantitative | 3,118 | 88.3% | 2.06x | 1,557 | 42 |
| 80053 Blood test, comprehensive group of blood chemicals | 3,060 | 88.4% | 2.22x | 1,492 | 48 |
| 81001 Manual urinalysis test with examination using microscope, automated | 2,707 | 87.0% | 2.01x | 1,200 | 42 |
| 71045 X-ray of chest, 1 view | 2,669 | 90.1% | 2.22x | 1,569 | 41 |
| 83690 Lipase (fat enzyme) level | 2,612 | 87.5% | 2.16x | 1,221 | 43 |
| 96374 Injection of drug or substance into vein | 2,511 | 88.8% | 2.20x | 1,258 | 42 |
| 99233 Subsequent hospital care with moderate levelof medical decision making, if using | 2,414 | 87.8% | 4.56x | 2,391 | 32 |
| 99232 Subsequent hospital care with moderate levelof medical decision making, if using | 2,048 | 87.1% | 33.08x † | 2,033 | 31 |
| 96361 Infusion into a vein for hydration, each additional hour | 2,016 | 89.0% | 2.16x | 963 | 43 |
| 96375 Injection of additional new drug or substance into vein | 1,943 | 88.3% | 2.16x | 966 | 42 |
| 81025 Urine pregnancy test | 1,888 | 88.0% | 2.29x | 855 | 44 |
| 99223 Initial hospital care with moderate level of medical decision making, if using t | 1,643 | 85.5% | 5.66x | 1,627 | 29 |
| 70450 CT scan head or brain without contrast | 1,540 | 88.1% | 2.22x | 857 | 41 |
| 96372 Injection of drug or substance under skin or into muscle | 1,534 | 90.8% | 2.55x | 620 | 43 |
| 95938 Placement of skin electrodes and measurement of stimulated sites on arms and leg | 1,434 | 88.4% | 29.62x † | 1,280 | 35 |
| 80076 Liver function blood test panel | 1,424 | 86.8% | 2.05x | 729 | 38.5 |
| 93010 Routine electrocardiogram (ECG) using at least 12 leads with interpretation and | 1,305 | 86.4% | 6.32x | 896 | 24 |
2025 Q1–Q4 · rows with n ≥ 30 determined line items · sorted by n.
Payers with the most determined line items in California
Payer = health plan/issuer email domain reported by CMS, with the most common plan name for that domain. Some domains belong to vendors acting for plans.
| Payer (email domain) | Line items | Win % | Median ×QPA | Ratio n | Median days |
|---|---|---|---|---|---|
| ANTHEM BLUE CROSS BLUE SHIELD (anthem.com) | 83,552 | 90.7% | 3.49x | 51,853 | 43 |
| AETNA (aetna.com) | 25,972 | 93.3% | 2.48x | 16,938 | 29 |
| CIGNA (cigna.com) | 25,817 | 84.2% | 2.26x | 23,242 | 36 |
| CIGNA (multiplan.com) | 22,523 | 83.9% | 1.90x | 19,029 | 31 |
| BLUE SHIELD PPO (blueshieldca.com) | 17,749 | 82.2% | 5.76x | 11,664 | 29 |
| UNITED HEALTHCARE (uhc.com) | 13,499 | 87.4% | 2.97x | 8,837 | 34 |
| UMR (clearhs.com) | 2,710 | 88.3% | 3.14x | 2,359 | 29 |
| UMR (clearhealthcloud.com) | 2,253 | 88.1% | 2.09x | 1,875 | 29 |
| KAISER FOUNDATION (kp.org) | 1,634 | 99.8% | 2.09x | 1,574 | 26 |
| CIGNA (zelis.com) | 1,491 | 98.0% | 2.67x | 1,272 | 42 |
2025 Q1–Q4 · rows with n ≥ 30 determined line items · sorted by n.
Dollar amounts by CPT code in California
| CPT code | Line items with $ | Total awarded | Median award | Median QPA | Award ×QPA |
|---|---|---|---|---|---|
| 99284 Emergency department visit with moderate level of medical decision making | 23,720 | $20.9M | $570 | $196 | 2.14x |
| 99285 Emergency department visit with high level of medical decision making | 22,341 | $32.2M | $756 | $281 | 1.87x |
| 99283 Emergency department visit with low level of medical decision making | 4,160 | $4.0M | $402 | $144 | 1.80x |
| 99291 Critical care, first 30-74 minutes | 3,342 | $7.6M | $1,149 | $354 | 2.23x |
| 85025 Complete blood cell count (red cells, white blood cell, platelets), automated te | 2,869 | $492,040 | $175 | $59 | 2.12x |
| 36415 Insertion of needle into vein for collection of blood sample | 2,510 | $127,340 | $40 | $14 | 1.01x |
| 99233 Subsequent hospital care with moderate levelof medical decision making, if using | 1,992 | $2.8M | $718 | $125 | 7.86x |
| 99232 Subsequent hospital care with moderate levelof medical decision making, if using | 1,841 | $5.4M | $4,000 | $85 | 28.47x |
| 71045 X-ray of chest, 1 view | 1,765 | $589,676 | $361 | $142 | 2.22x |
| 80048 Blood test, basic group of blood chemicals (Calcium, total) | 1,722 | $693,350 | $420 | $138 | 2.13x |
| 93005 Routine electrocardiogram (ECG) using at least 12 leads with tracing | 1,589 | $570,181 | $348 | $155 | 1.93x |
| 84484 Troponin (protein) analysis, quantitative | 1,386 | $392,279 | $259 | $120 | 2.06x |
| 99223 Initial hospital care with moderate level of medical decision making, if using t | 1,380 | $2.3M | $1,389 | $228 | 6.34x |
| 80053 Blood test, comprehensive group of blood chemicals | 1,250 | $715,790 | $628 | $167 | 2.35x |
| 96374 Injection of drug or substance into vein | 1,111 | $827,675 | $719 | $229 | 1.80x |
| 83690 Lipase (fat enzyme) level | 1,069 | $211,774 | $203 | $67 | 2.30x |
| 81001 Manual urinalysis test with examination using microscope, automated | 1,064 | $134,885 | $112 | $48 | 2.10x |
| 95938 Placement of skin electrodes and measurement of stimulated sites on arms and leg | 995 | $3.5M | $1,817 | $57 | 0.63x |
| 99239 Hospital discharge day management, more than 30 minutes | 989 | $545,943 | $553 | $128 | 3.90x |
| 70450 CT scan head or brain without contrast | 961 | $2.1M | $2,102 | $814 | 2.38x |
| 96375 Injection of additional new drug or substance into vein | 866 | $387,134 | $346 | $142 | 1.70x |
| 96361 Infusion into a vein for hydration, each additional hour | 861 | $497,851 | $483 | $149 | 1.73x |
| 99231 Subsequent hospital care with straightforward or low level of medical decision m | 800 | $3.0M | $4,625 | $49 | 56.65x |
| 95941 Continuous remote monitoring of nervous system during operation, each hour | 793 | $6.6M | $3,550 | $261 | 9.61x |
| 81025 Urine pregnancy test | 745 | $133,245 | $166 | $55 | 2.50x |
2025 Q1–Q4 · CMS QPA and Offers file · rows with n ≥ 30 line items with dollar amounts · sorted by n · Award ×QPA = total awarded ÷ total QPA.
FAQ
What is the Federal IDR provider win rate for services provided in California?
In 2025 Q1–Q4, the provider or facility offer was selected in 88.5% of 209,808 determined dispute line items for services provided in California. Split decisions are excluded from the denominator and default decisions are included. Withdrawn, settled and ineligible disputes are not in the CMS data.
How do Federal IDR payments compare with the QPA for services provided in California?
In 2025 Q1–Q4, the median prevailing offer was 2.63x the qualifying payment amount (QPA), with a 25th to 75th percentile range of 1.78x to 5.56x (n = 146,356 line items). This uses the CMS field Prevailing Party Offer as % of QPA, where 1.00x equals the QPA.
How long do Federal IDR decisions take for services provided in California?
In 2025 Q1–Q4, the median was 36 business days (n = 209,808 line items), using the CMS field Length of Time to Make Determination (from dispute initiation).
California figures count line items whose place of service was California. See methodology for caveats.