Federal IDR outcomes in Virginia
In 2025 Q1–Q4, the provider or facility offer prevailed in 84.2% of 69,753 determined Federal IDR dispute line items for services provided in Virginia. The median prevailing offer was 3.30x the QPA (25th–75th percentile 2.16x–5.01x; n = 66,339). The median time to a decision was 44 business days (n = 69,753).
Determined line items
69,753
2025 Q1–Q4 · 122 split decisions excluded
Provider win rate
84.2%
n = 69,753 · 2025 Q1–Q4
Median payment vs QPA
3.30x
middle half 2.16x–5.01x · n = 66,339 · 2025 Q1–Q4
Median days to decision
44
business days, from dispute initiation · n = 69,753 · 2025 Q1–Q4
Dollar amounts
Total awarded
$81.2M
sum of prevailing offers · n = 67,363 · 2025 Q1–Q4
Total QPA
$17.9M
sum of QPAs, same line items · n = 67,363 · 2025 Q1–Q4
Awarded above QPA
$63.3M
total awarded minus total QPA · n = 67,363 · 2025 Q1–Q4
Median award per line item
$791
mean $1,205 · n = 67,363 · 2025 Q1–Q4
Median QPA
$207
per line item · n = 67,363 · 2025 Q1–Q4
Award vs QPA, dollar-weighted
4.54x
total awarded ÷ total QPA · n = 67,363 · 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 | 67,363 | $81.2M | $17.9M | $63.3M | $791 | $207 | 4.54x |
| 2024 Q3–Q4 | 30,212 | $24.4M | $18.8M | $5.6M | $674 | $193 | 1.30x |
| 2024 Q3–2025 Q4 | 97,575 | $105.6M | $36.7M | $68.9M | $750 | $203 | 2.88x |
| 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 | 69,753 | 84.2% | 3.30x | 2.16x–5.01x | 66,339 | 44 |
| 2024 Q1–Q4 | 55,807 | 85.5% | 2.94x | 2.23x–4.31x | 51,136 | 145 |
| 2023 Q1–Q4 | 10,240 | 84.7% | 3.07x | 2.04x–4.33x | 9,886 | 93 |
| 2023 Q1–2025 Q4 | 135,800 | 84.8% | 3.09x | 2.18x–4.79x | 127,361 | 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 Virginia
| Specialty group | Line items | Win % | Median ×QPA | Ratio n | Median days |
|---|---|---|---|---|---|
| Emergency medicine and emergency departments | 54,185 | 85.6% | 3.04x | 51,493 | 49 |
| Anesthesiology | 5,792 | 79.6% | 3.57x | 5,685 | 30 |
| Intraoperative neuromonitoring | 4,284 | 87.0% | 18.04x | 3,787 | 37.5 |
| Plastic and reconstructive surgery | 2,024 | 89.3% | 8.07x | 1,977 | 35 |
| Hospital medicine (hospitalists) | 2,008 | 83.6% | 2.75x | 1,992 | 35 |
| Not reported / unspecified | 949 | 7.4% | 1.13x | 897 | 54 |
| Internal and family medicine | 271 | 84.9% | 5.48x | 269 | 47 |
| Neurology | 95 | 82.1% | 22.98x † | 94 | 42 |
| Laboratory and pathology | 78 | 94.9% | 1.00x | 78 | 87 |
2025 Q1–Q4 · rows with n ≥ 30 determined line items · sorted by n.
Most disputed CPT codes in Virginia
| CPT code | Line items | Win % | Median ×QPA | Ratio n | Median days |
|---|---|---|---|---|---|
| 99284 Emergency department visit with moderate level of medical decision making | 30,474 | 83.5% | 3.14x | 28,979 | 48 |
| 99285 Emergency department visit with high level of medical decision making | 18,056 | 87.8% | 3.15x | 17,246 | 47 |
| 99283 Emergency department visit with low level of medical decision making | 3,387 | 86.8% | 2.84x | 3,126 | 69 |
| 99291 Critical care, first 30-74 minutes | 2,086 | 79.4% | 3.18x | 2,011 | 46 |
| 95938 Placement of skin electrodes and measurement of stimulated sites on arms and leg | 1,403 | 86.6% | 24.72x † | 1,245 | 38 |
| 99232 Subsequent hospital care with moderate levelof medical decision making, if using | 1,339 | 86.3% | 3.77x | 1,314 | 57 |
| 95941 Continuous remote monitoring of nervous system during operation, each hour | 1,251 | 89.1% | 14.31x | 1,121 | 41 |
| 00812 Anesthesia for exam of colon using an endoscope | 1,011 | 77.7% | 2.53x | 1,000 | 38 |
| 99233 Subsequent hospital care with moderate levelof medical decision making, if using | 817 | 72.9% | 2.26x | 793 | 38 |
| 95939 Placement of skin electrodes and measurement of central motor stimulation in arm | 637 | 86.3% | 11.85x | 586 | 33 |
| 00731 Anesthesia for other procedure on esophagus, stomach, or upper small bowel using | 510 | 79.0% | 3.03x | 509 | 35 |
| 99223 Initial hospital care with moderate level of medical decision making, if using t | 396 | 72.2% | 1.90x | 395 | 38 |
| 00840 Anesthesia for other procedure on lower abdomen | 360 | 76.4% | 5.89x | 355 | 29 |
| 00811 Anesthesia for other procedure on large bowel using an endoscope | 276 | 78.6% | 2.67x | 269 | 44.5 |
| 99239 Hospital discharge day management, more than 30 minutes | 267 | 58.1% | 1.69x | 267 | 26 |
| 00813 Anesthesia for procedure on small and large bowel using an endoscope | 255 | 78.4% | 3.50x | 254 | 31 |
| 01967 Anesthesia for labor during planned vaginal delivery | 217 | 75.6% | 2.26x | 216 | 25 |
| 01961 Anesthesia for cesarean delivery | 202 | 87.6% | 6.12x | 200 | 30.5 |
| 00790 Anesthesia for other procedure on upper abdomen | 197 | 73.1% | 5.30x | 187 | 33 |
| 95870 Needle measurement of electrical activity in arm, leg, trunk or head muscles, li | 168 | 89.3% | 9.16x | 112 | 62.5 |
| 95861 Needle measurement of electrical activity in arm or leg muscles, 2 extremities | 157 | 90.4% | 20.27x † | 123 | 38 |
| 95937 Testing of nerve-muscle junction | 140 | 87.1% | 38.51x † | 91 | 32 |
| 01400 Anesthesia for other procedure or exam of knee joint using an endoscope | 121 | 47.1% | 1.25x | 111 | 62 |
| 95955 Measurement of brain wave activity (EEG) outside the brain during surgery | 120 | 77.5% | 103.87x † | 120 | 34.5 |
| 00952 Anesthesia for exam of uterus using an endoscope | 115 | 77.4% | 5.95x | 107 | 30 |
2025 Q1–Q4 · rows with n ≥ 30 determined line items · sorted by n.
Payers with the most determined line items in Virginia
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) | 28,606 | 85.1% | 4.42x | 28,294 | 45 |
| UNITED HEALTHCARE (uhc.com) | 14,756 | 84.7% | 2.74x | 13,891 | 37 |
| CIGNA (cigna.com) | 10,471 | 79.9% | 2.61x | 9,229 | 59 |
| AETNA (aetna.com) | 3,541 | 78.5% | 2.08x | 3,511 | 62 |
| CIGNA (multiplan.com) | 3,502 | 82.7% | 3.87x | 2,940 | 111 |
| UMR (clearhealthcloud.com) | 3,273 | 88.3% | 2.00x | 3,176 | 46 |
| UMR (clearhs.com) | 2,206 | 82.7% | 2.99x | 2,171 | 28 |
| CIGNA (zelis.com) | 841 | 99.3% | 3.35x | 719 | 367 |
| CAREFIRST (carefirst.com) | 635 | 82.2% | 8.59x | 613 | 40 |
| SENTARA HEALTH PLANS (sentara.com) | 454 | 98.9% | 3.94x | 445 | 41 |
2025 Q1–Q4 · rows with n ≥ 30 determined line items · sorted by n.
Dollar amounts by CPT code in Virginia
| CPT code | Line items with $ | Total awarded | Median award | Median QPA | Award ×QPA |
|---|---|---|---|---|---|
| 99284 Emergency department visit with moderate level of medical decision making | 29,795 | $20.7M | $685 | $182 | 3.39x |
| 99285 Emergency department visit with high level of medical decision making | 18,677 | $19.3M | $1,013 | $258 | 3.62x |
| 99283 Emergency department visit with low level of medical decision making | 4,026 | $1.4M | $252 | $129 | 2.78x |
| 99291 Critical care, first 30-74 minutes | 2,423 | $3.1M | $1,325 | $309 | 3.78x |
| 99232 Subsequent hospital care with moderate levelof medical decision making, if using | 1,423 | $436,771 | $278 | $76 | 3.49x |
| 00812 Anesthesia for exam of colon using an endoscope | 1,193 | $1.4M | $1,200 | $424 | 2.99x |
| 99233 Subsequent hospital care with moderate levelof medical decision making, if using | 1,098 | $543,978 | $395 | $124 | 3.36x |
| 95938 Placement of skin electrodes and measurement of stimulated sites on arms and leg | 973 | $2.5M | $1,817 | $60 | 15.59x |
| 95941 Continuous remote monitoring of nervous system during operation, each hour | 763 | $5.1M | $3,309 | $248 | 14.05x |
| 00731 Anesthesia for other procedure on esophagus, stomach, or upper small bowel using | 519 | $768,030 | $1,512 | $450 | 3.46x |
| 99223 Initial hospital care with moderate level of medical decision making, if using t | 490 | $424,756 | $673 | $225 | 3.81x |
| 99239 Hospital discharge day management, more than 30 minutes | 451 | $281,972 | $625 | $123 | 4.99x |
| 95939 Placement of skin electrodes and measurement of central motor stimulation in arm | 421 | $1.2M | $2,229 | $161 | 11.87x |
| 00840 Anesthesia for other procedure on lower abdomen | 409 | $1.3M | $3,408 | $641 | 4.61x |
| 00811 Anesthesia for other procedure on large bowel using an endoscope | 316 | $400,808 | $1,296 | $450 | 3.27x |
| 00813 Anesthesia for procedure on small and large bowel using an endoscope | 280 | $481,237 | $1,981 | $440 | 3.60x |
| 00790 Anesthesia for other procedure on upper abdomen | 243 | $772,134 | $3,679 | $682 | 3.18x |
| 01967 Anesthesia for labor during planned vaginal delivery | 193 | $1.0M | $6,450 | $2,526 | 2.21x |
| 01961 Anesthesia for cesarean delivery | 177 | $593,300 | $3,692 | $624 | 5.00x |
| 99222 Initial hospital care with straightforward or low-level medical decision making, | 128 | $125,297 | $948 | $145 | 6.42x |
| 00400 Anesthesia for other procedure on skin of arms, legs, and front body | 125 | $230,100 | $1,981 | $327 | 5.19x |
| 00952 Anesthesia for exam of uterus using an endoscope | 111 | $221,441 | $2,264 | $353 | 5.67x |
| 01400 Anesthesia for other procedure or exam of knee joint using an endoscope | 99 | $202,371 | $1,303 | $473 | 3.61x |
| 95861 Needle measurement of electrical activity in arm or leg muscles, 2 extremities | 98 | $296,614 | $2,508 | $118 | 16.65x |
| 00918 Anesthesia for fragmenting, manipulation and/or removal of kidney stone includin | 97 | $222,590 | $2,556 | $421 | 5.41x |
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 Virginia?
In 2025 Q1–Q4, the provider or facility offer was selected in 84.2% of 69,753 determined dispute line items for services provided in Virginia. 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 Virginia?
In 2025 Q1–Q4, the median prevailing offer was 3.30x the qualifying payment amount (QPA), with a 25th to 75th percentile range of 2.16x to 5.01x (n = 66,339 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 Virginia?
In 2025 Q1–Q4, the median was 44 business days (n = 69,753 line items), using the CMS field Length of Time to Make Determination (from dispute initiation).
Virginia figures count line items whose place of service was Virginia. See methodology for caveats.