Federal IDR outcomes in Rhode Island
In 2025 Q1–Q4, the provider or facility offer prevailed in 86.0% of 5,701 determined Federal IDR dispute line items for services provided in Rhode Island. The median prevailing offer was 3.48x the QPA (25th–75th percentile 1.93x–5.65x; n = 4,498). The median time to a decision was 38 business days (n = 5,701).
Determined line items
5,701
2025 Q1–Q4 · 7 split decisions excluded
Provider win rate
86.0%
n = 5,701 · 2025 Q1–Q4
Median payment vs QPA
3.48x
middle half 1.93x–5.65x · n = 4,498 · 2025 Q1–Q4
Median days to decision
38
business days, from dispute initiation · n = 5,701 · 2025 Q1–Q4
Dollar amounts
Total awarded
$2.1M
sum of prevailing offers · n = 2,778 · 2025 Q1–Q4
Total QPA
$694,359
sum of QPAs, same line items · n = 2,778 · 2025 Q1–Q4
Awarded above QPA
$1.4M
total awarded minus total QPA · n = 2,778 · 2025 Q1–Q4
Median award per line item
$581
mean $743 · n = 2,778 · 2025 Q1–Q4
Median QPA
$228
per line item · n = 2,778 · 2025 Q1–Q4
Award vs QPA, dollar-weighted
2.97x
total awarded ÷ total QPA · n = 2,778 · 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 | 2,778 | $2.1M | $694,359 | $1.4M | $581 | $228 | 2.97x |
| 2024 Q3–Q4 | 1,777 | $1.2M | $336,205 | $872,833 | $529 | $172 | 3.60x |
| 2024 Q3–2025 Q4 | 4,555 | $3.3M | $1.0M | $2.2M | $569 | $200 | 3.18x |
| 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 | 5,701 | 86.0% | 3.48x | 1.93x–5.65x | 4,498 | 38 |
| 2024 Q1–Q4 | 4,377 | 78.1% | 3.51x | 2.37x–8.06x | 3,831 | 120 |
| 2023 Q1–Q4 | 976 | 59.7% | 2.20x | 1.00x–3.86x | 907 | 89 |
| 2023 Q1–2025 Q4 | 11,054 | 80.5% | 3.48x | 1.93x–5.71x | 9,236 | 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 Rhode Island
| Specialty group | Line items | Win % | Median ×QPA | Ratio n | Median days |
|---|---|---|---|---|---|
| Hospitals and facilities | 2,589 | 91.0% | 3.02x | 1,447 | 40 |
| Emergency medicine and emergency departments | 2,069 | 81.3% | 2.57x | 2,069 | 34 |
| Intraoperative neuromonitoring | 947 | 86.9% | 13.27x | 928 | 31 |
| Not reported / unspecified | 46 | 2.2% | – | 18 | 17 |
| Plastic and reconstructive surgery | 34 | 88.2% | – | 24 | 25.5 |
2025 Q1–Q4 · rows with n ≥ 30 determined line items · sorted by n.
Most disputed CPT codes in Rhode Island
| CPT code | Line items | Win % | Median ×QPA | Ratio n | Median days |
|---|---|---|---|---|---|
| 99285 Emergency department visit with high level of medical decision making | 882 | 88.5% | 2.16x | 843 | 34 |
| 99284 Emergency department visit with moderate level of medical decision making | 856 | 88.2% | 2.83x | 830 | 49 |
| 99283 Emergency department visit with low level of medical decision making | 327 | 58.4% | 2.53x | 321 | 188 |
| 95938 Placement of skin electrodes and measurement of stimulated sites on arms and leg | 317 | 86.4% | 26.91x † | 313 | 29 |
| 95939 Placement of skin electrodes and measurement of central motor stimulation in arm | 219 | 84.9% | 12.54x | 216 | 31 |
| 95941 Continuous remote monitoring of nervous system during operation, each hour | 163 | 90.8% | 7.81x | 159 | 28 |
| 85025 Complete blood cell count (red cells, white blood cell, platelets), automated te | 148 | 86.5% | 5.12x | 113 | 40 |
| 36415 Insertion of needle into vein for collection of blood sample | 122 | 91.0% | – | 16 | 40 |
| 80053 Blood test, comprehensive group of blood chemicals | 93 | 88.2% | 9.65x | 75 | 42 |
| 84484 Troponin (protein) analysis, quantitative | 82 | 82.9% | 4.28x | 60 | 41 |
| 83690 Lipase (fat enzyme) level | 78 | 87.2% | 4.05x | 64 | 42 |
| 96361 Infusion into a vein for hydration, each additional hour | 70 | 94.3% | 1.00x | 47 | 35.5 |
| 96374 Injection of drug or substance into vein | 70 | 92.9% | – | 22 | 36.5 |
| 93005 Routine electrocardiogram (ECG) using at least 12 leads with tracing | 67 | 92.5% | 2.86x | 53 | 42 |
| 99291 Critical care, first 30-74 minutes | 64 | 65.6% | 2.90x | 63 | 35 |
| 96375 Injection of additional new drug or substance into vein | 59 | 96.6% | – | 22 | 40 |
| 80048 Blood test, basic group of blood chemicals (Calcium, total) | 55 | 85.5% | 6.84x | 44 | 39 |
| 95861 Needle measurement of electrical activity in arm or leg muscles, 2 extremities | 51 | 80.4% | 11.80x | 47 | 34 |
| 99223 Initial hospital care with moderate level of medical decision making, if using t | 51 | 54.9% | 2.78x | 51 | 43 |
| 71046 X-ray of chest, 2 views | 42 | 90.5% | 2.45x | 33 | 38.5 |
| 95955 Measurement of brain wave activity (EEG) outside the brain during surgery | 39 | 92.3% | 24.08x † | 36 | 35 |
| 83735 Magnesium level | 38 | 84.2% | – | 26 | 40 |
| 81025 Urine pregnancy test | 37 | 89.2% | 5.58x | 32 | 35 |
| 74177 CT scan of abdomen and pelvis with contrast | 36 | 100.0% | – | 28 | 44 |
| 81003 Automated urinalysis test | 34 | 88.2% | – | 20 | 37 |
2025 Q1–Q4 · rows with n ≥ 30 determined line items · sorted by n.
Payers with the most determined line items in Rhode Island
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) | 1,565 | 86.9% | 2.13x | 1,562 | 29 |
| HARVARD PILGRIM (point32health.org) | 1,223 | 89.9% | 4.21x | 753 | 40 |
| CIGNA (multiplan.com) | 948 | 77.6% | 4.40x | 774 | 77 |
| UNITED HEALTHCARE (uhc.com) | 321 | 79.4% | 12.54x | 311 | 39 |
| BCBS RI (bcbsri.org) | 198 | 97.5% | 16.73x | 140 | 26 |
| UMR (clearhs.com) | 162 | 90.7% | 3.80x | 144 | 38 |
| CIGNA (cigna.com) | 158 | 98.1% | 1.62x | 88 | 69 |
| FLORIDA BLUE (bcbsfl.com) | 157 | 92.4% | 14.31x | 153 | 24 |
| BCBSTX (bcbstx.com) | 132 | 91.7% | 16.75x | 125 | 28.5 |
| NEIGHBORHOOD HEALTH PLAN OF RI (nhpri.org) | 100 | 95.0% | 27.78x † | 34 | 41 |
2025 Q1–Q4 · rows with n ≥ 30 determined line items · sorted by n.
Dollar amounts by CPT code in Rhode Island
| CPT code | Line items with $ | Total awarded | Median award | Median QPA | Award ×QPA |
|---|---|---|---|---|---|
| 99285 Emergency department visit with high level of medical decision making | 938 | $745,761 | $772 | $365 | 2.16x |
| 99284 Emergency department visit with moderate level of medical decision making | 805 | $434,139 | $569 | $267 | 2.29x |
| 99283 Emergency department visit with low level of medical decision making | 307 | $92,486 | $375 | $84 | 2.66x |
| 95938 Placement of skin electrodes and measurement of stimulated sites on arms and leg | 172 | $242,026 | $1,817 | $66 | 13.74x |
| 95939 Placement of skin electrodes and measurement of central motor stimulation in arm | 109 | $186,299 | $2,229 | $174 | 8.30x |
| 85025 Complete blood cell count (red cells, white blood cell, platelets), automated te | 50 | $7,259 | $105 | $20 | 4.39x |
| 99291 Critical care, first 30-74 minutes | 45 | $40,529 | $906 | $308 | 2.84x |
| 99223 Initial hospital care with moderate level of medical decision making, if using t | 41 | $30,854 | $781 | $281 | 2.69x |
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 Rhode Island?
In 2025 Q1–Q4, the provider or facility offer was selected in 86.0% of 5,701 determined dispute line items for services provided in Rhode Island. 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 Rhode Island?
In 2025 Q1–Q4, the median prevailing offer was 3.48x the qualifying payment amount (QPA), with a 25th to 75th percentile range of 1.93x to 5.65x (n = 4,498 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 Rhode Island?
In 2025 Q1–Q4, the median was 38 business days (n = 5,701 line items), using the CMS field Length of Time to Make Determination (from dispute initiation).
Rhode Island figures count line items whose place of service was Rhode Island. See methodology for caveats.