Federal IDR outcomes in Pennsylvania
In 2025 Q1–Q4, the provider or facility offer prevailed in 90.4% of 42,822 determined Federal IDR dispute line items for services provided in Pennsylvania. The median prevailing offer was 4.45x the QPA (25th–75th percentile 2.94x–14.52x; n = 24,584). The median time to a decision was 34 business days (n = 42,822).
Determined line items
42,822
2025 Q1–Q4 · 20 split decisions excluded
Provider win rate
90.4%
n = 42,822 · 2025 Q1–Q4
Median payment vs QPA
4.45x
middle half 2.94x–14.52x · n = 24,584 · 2025 Q1–Q4
Median days to decision
34
business days, from dispute initiation · n = 42,822 · 2025 Q1–Q4
Dollar amounts
Total awarded
$2.24B
sum of prevailing offers · n = 216,587 · 2025 Q1–Q4
Total QPA
$171.7M
sum of QPAs, same line items · n = 216,587 · 2025 Q1–Q4
Awarded above QPA
$2.07B
total awarded minus total QPA · n = 216,587 · 2025 Q1–Q4
Median award per line item
$1,225
mean $10,338 · n = 216,587 · 2025 Q1–Q4
Median QPA
$190
per line item · n = 216,587 · 2025 Q1–Q4
Award vs QPA, dollar-weighted
13.04x
total awarded ÷ total QPA · n = 216,587 · 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 | 216,587 | $2.24B | $171.7M | $2.07B | $1,225 | $190 | 13.04x |
| 2024 Q3–Q4 | 69,417 | $559.2M | $50.9M | $508.3M | $945 | $189 | 10.99x |
| 2024 Q3–2025 Q4 | 286,004 | $2.80B | $222.6M | $2.58B | $1,158 | $189 | 12.57x |
| 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 | 42,822 | 90.4% | 4.45x | 2.94x–14.52x | 24,584 | 34 |
| 2024 Q1–Q4 | 17,386 | 88.3% | 4.86x | 2.64x–12.55x | 12,624 | 45 |
| 2023 Q1–Q4 | 1,937 | 76.0% | 3.19x | 1.76x–11.91x | 1,770 | 61 |
| 2023 Q1–2025 Q4 | 62,145 | 89.4% | 4.54x | 2.78x–13.10x | 38,978 | 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 Pennsylvania
| Specialty group | Line items | Win % | Median ×QPA | Ratio n | Median days |
|---|---|---|---|---|---|
| Hospitals and facilities | 21,362 | 94.3% | 3.20x | 5,840 | 35 |
| Intraoperative neuromonitoring | 9,393 | 86.7% | 15.34x | 8,097 | 28 |
| Emergency medicine and emergency departments | 6,199 | 88.9% | 3.12x | 6,030 | 45 |
| Anesthesiology | 3,846 | 86.5% | 8.09x | 3,681 | 30 |
| Not reported / unspecified | 1,203 | 77.1% | 1.36x | 200 | 18 |
| Plastic and reconstructive surgery | 156 | 76.3% | 5.11x | 150 | 23 |
| Orthopedic surgery | 141 | 87.9% | 405.11x † | 136 | 17 |
| Neurosurgery and spine surgery | 117 | 83.8% | 61.10x † | 112 | 34 |
| Neurology | 95 | 88.4% | 62.12x † | 94 | 27 |
| Other / unclassified labels | 86 | 43.0% | 1.05x | 85 | 84 |
| Vascular surgery | 69 | 98.6% | – | 23 | 27 |
| Neonatology | 43 | 74.4% | 4.28x | 43 | 145 |
| Pain medicine | 34 | 76.5% | – | 17 | 33 |
2025 Q1–Q4 · rows with n ≥ 30 determined line items · sorted by n.
Most disputed CPT codes in Pennsylvania
| CPT code | Line items | Win % | Median ×QPA | Ratio n | Median days |
|---|---|---|---|---|---|
| 99284 Emergency department visit with moderate level of medical decision making | 4,257 | 90.1% | 3.06x | 4,105 | 45 |
| 95938 Placement of skin electrodes and measurement of stimulated sites on arms and leg | 2,743 | 87.6% | 27.14x † | 2,446 | 28 |
| 99285 Emergency department visit with high level of medical decision making | 2,325 | 85.5% | 2.81x | 2,216 | 38 |
| 95939 Placement of skin electrodes and measurement of central motor stimulation in arm | 2,044 | 88.0% | 13.10x | 1,957 | 27 |
| 95941 Continuous remote monitoring of nervous system during operation, each hour | 1,672 | 86.3% | 8.12x | 1,482 | 27 |
| 36415 Insertion of needle into vein for collection of blood sample | 1,168 | 94.7% | 3.79x | 162 | 34 |
| 85025 Complete blood cell count (red cells, white blood cell, platelets), automated te | 984 | 94.1% | 3.78x | 199 | 34 |
| 99283 Emergency department visit with low level of medical decision making | 869 | 92.8% | 3.75x | 826 | 43 |
| 80053 Blood test, comprehensive group of blood chemicals | 635 | 96.4% | 3.72x | 119 | 35 |
| 00142 Anesthesia for lens surgery | 562 | 81.5% | 16.17x | 550 | 29 |
| 95861 Needle measurement of electrical activity in arm or leg muscles, 2 extremities | 552 | 84.8% | 10.21x | 401 | 28 |
| 93005 Routine electrocardiogram (ECG) using at least 12 leads with tracing | 550 | 95.3% | 3.24x | 98 | 34 |
| 96374 Injection of drug or substance into vein | 534 | 92.9% | 2.48x | 132 | 34 |
| 80048 Blood test, basic group of blood chemicals (Calcium, total) | 532 | 91.0% | 4.12x | 92 | 28.5 |
| 84484 Troponin (protein) analysis, quantitative | 530 | 94.0% | 3.79x | 98 | 35 |
| 83690 Lipase (fat enzyme) level | 473 | 93.4% | 3.76x | 89 | 35 |
| 81025 Urine pregnancy test | 448 | 94.2% | 3.99x | 76 | 33 |
| 96361 Infusion into a vein for hydration, each additional hour | 400 | 93.8% | 4.18x | 115 | 34.5 |
| 01400 Anesthesia for other procedure or exam of knee joint using an endoscope | 393 | 89.3% | 9.23x | 366 | 30 |
| 95870 Needle measurement of electrical activity in arm, leg, trunk or head muscles, li | 391 | 84.4% | 7.65x | 351 | 34 |
| 95937 Testing of nerve-muscle junction | 371 | 83.0% | 19.71x | 222 | 31 |
| 81003 Automated urinalysis test | 357 | 94.4% | 3.52x | 61 | 34 |
| 96375 Injection of additional new drug or substance into vein | 349 | 92.8% | 4.04x | 90 | 34 |
| 81001 Manual urinalysis test with examination using microscope, automated | 346 | 94.2% | 4.47x | 54 | 34 |
| 99291 Critical care, first 30-74 minutes | 305 | 95.7% | 3.85x | 291 | 30 |
2025 Q1–Q4 · rows with n ≥ 30 determined line items · sorted by n.
Payers with the most determined line items in Pennsylvania
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 |
|---|---|---|---|---|---|
| AETNA (aetna.com) | 11,914 | 90.5% | 4.39x | 3,764 | 27 |
| BCBS OF PA (ibx.com) | 7,581 | 98.7% | 13.10x | 2,270 | 35 |
| UNITED HEALTHCARE (uhc.com) | 6,839 | 86.0% | 3.22x | 6,717 | 43 |
| BCBS HIGHMARK (highmark.com) | 3,151 | 82.6% | 15.91x | 2,390 | 30 |
| AMBETTER (centene.com) | 2,603 | 97.3% | 4.31x | 865 | 36 |
| UMR (clearhs.com) | 2,065 | 86.5% | 4.28x | 1,883 | 30 |
| CIGNA (cigna.com) | 1,584 | 78.0% | 3.32x | 1,325 | 39 |
| FLORIDA BLUE (bcbsfl.com) | 1,518 | 93.4% | 12.41x | 1,459 | 23 |
| UMR (clearhealthcloud.com) | 1,000 | 86.1% | 3.16x | 923 | 34 |
| CIGNA (multiplan.com) | 589 | 81.7% | 3.78x | 393 | 39 |
2025 Q1–Q4 · rows with n ≥ 30 determined line items · sorted by n.
Dollar amounts by CPT code in Pennsylvania
| CPT code | Line items with $ | Total awarded | Median award | Median QPA | Award ×QPA |
|---|---|---|---|---|---|
| 99284 Emergency department visit with moderate level of medical decision making | 18,844 | $15.7M | $658 | $311 | 2.89x |
| 99285 Emergency department visit with high level of medical decision making | 7,924 | $10.0M | $879 | $313 | 2.95x |
| 71045 X-ray of chest, 1 view | 7,262 | $587,555 | $90 | $11 | 6.51x |
| 95938 Placement of skin electrodes and measurement of stimulated sites on arms and leg | 5,950 | $29.8M | $5,000 | $57 | 21.65x |
| 99283 Emergency department visit with low level of medical decision making | 5,170 | $5.2M | $473 | $175 | 5.75x |
| 99232 Subsequent hospital care with moderate levelof medical decision making, if using | 4,519 | $9.6M | $1,400 | $83 | 17.62x |
| 99233 Subsequent hospital care with moderate levelof medical decision making, if using | 3,850 | $6.5M | $726 | $114 | 4.83x |
| 95939 Placement of skin electrodes and measurement of central motor stimulation in arm | 3,776 | $25.0M | $6,056 | $145 | 17.10x |
| 74177 CT scan of abdomen and pelvis with contrast | 3,716 | $2.8M | $869 | $168 | 4.46x |
| 71046 X-ray of chest, 2 views | 3,362 | $320,713 | $116 | $12 | 6.35x |
| 95941 Continuous remote monitoring of nervous system during operation, each hour | 3,233 | $27.6M | $4,963 | $450 | 9.02x |
| 70450 CT scan head or brain without contrast | 3,067 | $997,211 | $360 | $75 | 4.00x |
| 76641 Complete ultrasound scan of 1 breast | 3,033 | $781,336 | $298 | $49 | 6.03x |
| 77067 Screening mammography | 2,572 | $405,604 | $171 | $52 | 3.08x |
| 99291 Critical care, first 30-74 minutes | 2,546 | $6.6M | $1,120 | $248 | 5.86x |
| 00142 Anesthesia for lens surgery | 2,459 | $10.8M | $5,680 | $391 | 8.67x |
| 77063 Screening 3D breast mammography | 2,349 | $269,735 | $121 | $51 | 2.40x |
| 95861 Needle measurement of electrical activity in arm or leg muscles, 2 extremities | 2,246 | $7.8M | $3,381 | $110 | 15.18x |
| 22853 Insertion of cage or mesh device to spine bone and disc space during spine fusio | 2,052 | $69.3M | $36,000 | $273 | 18.71x |
| 19318 Breast reduction | 1,978 | $146.7M | $72,000 | $1,254 | 33.29x |
| 74176 CT scan of abdomen and pelvis without contrast | 1,515 | $1.1M | $831 | $163 | 4.49x |
| 99223 Initial hospital care with moderate level of medical decision making, if using t | 1,408 | $3.6M | $1,508 | $203 | 8.74x |
| 00812 Anesthesia for exam of colon using an endoscope | 1,405 | $3.6M | $1,698 | $544 | 4.75x |
| 71275 CT scan of blood vessels of chest with contrast | 1,393 | $987,194 | $855 | $163 | 4.61x |
| 64483 Injection of anesthetic and/or steroid drug into sacral spine nerve root using i | 1,261 | $16.0M | $11,723 | $236 | 26.59x |
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 Pennsylvania?
In 2025 Q1–Q4, the provider or facility offer was selected in 90.4% of 42,822 determined dispute line items for services provided in Pennsylvania. 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 Pennsylvania?
In 2025 Q1–Q4, the median prevailing offer was 4.45x the qualifying payment amount (QPA), with a 25th to 75th percentile range of 2.94x to 14.52x (n = 24,584 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 Pennsylvania?
In 2025 Q1–Q4, the median was 34 business days (n = 42,822 line items), using the CMS field Length of Time to Make Determination (from dispute initiation).
Pennsylvania figures count line items whose place of service was Pennsylvania. See methodology for caveats.