The QPA has been a leading cause of frustration within the physician community since 2021. The statute passed by Congress described the QPA as “… the median of the contracted rates recognized by the plan or issuer… within the same insurance market… as the total maximum payment… under such plan or coverage… on January 31, 2019, for the same or similar item or service that is provided by a provider in the same or similar specialty and provided in the geographic region in which the item or service is furnished… increased by the percentage increase in the consumer price index for all urban consumers.”

In other words take all of the health plan’s contracts for a given item or service, remove contracts with physicians of unrelated specialties, remove contracts outside of the relevant geographic location, remove contracts from unrelated market types (i.e., group, individual, etc.), align those contracts from smallest to largest, and adjust annually for inflation. The rate in the middle of that line is your QPA.

What concerned the physician community wasn’t this definition, but the Tri-Departments methodology for implementing it.

“Ghost Rates”

When it comes to rulemaking, the job of regulators is to fill in the fine details left open by Congress. If the law is a building, Congress is responsible for drafting the blueprint. They decide what the building is to be used for, whether it’s a stadium or a condo, the square footage, the layout, and the floorplan. Regulators construct the building, but the designs on the blueprint aren’t optional; they can’t decide to leave out the kitchen if the blueprint calls for one. The choice between imported hardwood or shag carpet is theirs to make, however.

It wasn’t the builder grade fixtures that led to yesterday’s result in TMA III, it was the gaping hole where the QPA’s guardrails were supposed to be.

When the first Interim Final Rule implementing the NSA was released in July, 2021, providers were concerned. The statutory requirement to calculate the QPA using contracts with “the same or similar specialty” became optional under the regulatory framework, requiring such a distinction only “if the plan or issuer has contracted rates for a service that vary based on provider specialty.” The Departments then granted even more deference to the plans, allowing them to define “same or similar specialty” in whatever way was “consistent with the plan’s or issuer’s usual business practice.” It was the regulatory equivalent of “do whatever you’d like.”

The predictable result of allowing the insurers to dim the lights inside what was already a black box was the proliferation of QPAs bearing no resemblance whatsoever to the median in-network rates they were meant to approximate. The first meaningful research on this issue was Avalere’s PCP Contracting Practices and Qualified Payment Amount Calculation Under the No Surprises Act, published on August 2, 2022 (sponsored by the American Society of Anesthesiologist (ASA), American College of Radiology (ACR), and the American College of Emergency Physicians(ACEP)). Avalere found that 68% of physicians surveyed had contracts for services they rarely provide and that 57% had contracts for services they never provide. Importantly, most respondents who contract for services they rarely or never provide stated that “they do not actively negotiate the rates for those services, implying they accept the rates offered by insurers.” This research was cited as persuasive in the Fifth Circuit’s decision yesterday in TMA III.

In December 2025, NDP Analytics published an analysis of QPAs in comparison to contracted rates disclosed through Transparency in Coverage (TiC) files, Rate Expectations: Evaluating the Validity of the QPAs Reported Under the No Surprises Act (sponsored by Americans for Fair Healthcare(AFHC)). Further corroborating Avalere’s findings, NDP Analytics found that median in-network rates in the TiC files were higher than QPAs 60.6% of the time. More shocking than the frequency of disagreement between medians was the magnitude; “…on average, [these] median in-network rates were 290.5% higher than reported QPAs.”

The provider community has known for years that QPAs don’t match in-network rates - they’ve lived it on every out-of-network claim since 2022, because initial payments most frequently reflect these deflated QPAs. The Fifth Circuit addressed the issue succinctly when it said:

“The inclusion of ghost rates in the QPA calculation is no minor problem. One survey, for example, found that 68% of primary care professionals have contracts with rates for services they perform fewer than twice annually, and 57% of respondents had contracts with rates for services that they never provide. Indeed, even the agencies acknowledge this practice. In the August FAQs, they reported that some insurers “offer[] most providers the same fee schedule for all covered services, and then it is up to the providers to negotiate increases to the rates for the services that they are most likely to bill. The agencies’ error has upended the NSA’s dispute-resolution process… Because the agencies directed insurers to include non-negotiated ghost rates, the resulting QPAs were artificially low.”

The court’s statements are even more prescient in light of the recently released Q3/Q4 2025 IDR Public Use Files (PUFs), which continue to demonstrate that insurers are driving utilization and outcomes under the NSA’s IDR process. According to CMS’ data, insurers made an offer equal to or less than the QPA in 51% of disputes for CY25. Insurers made offers of $1 or less in 9.5% of disputes over the same time period. They lost by default 24% of the time, failing to make any offer at all.

With QPAs so detached from the median in-network rate (and an embarrassingly frequent failure to even participate in the process), it’s no wonder insurers continue to lose in arbitration.

Why TMA III Matters

We’ve been waiting for clarity on broken QPAs for the better part of six years. With the Fifth Circuit’s decision, new rules will require insurers to actually exclude ghost rates when they calculate QPAs. They’ll also be required to include the total in-network rate, including bonus and incentive payments that are included in those contracts. This should lead to QPAs that are less laughable and more reflective of existing contracts.

In the meantime, audits of QPA calculations have languished. To the public’s knowledge, there are at least 25 pending and partially completed departmental audits of QPAs. With the offending provisions of the QPA methodology vacated, the departments should finalize and release these audits - then they should do more of them. Plans should be required to recalculate QPAs quickly; they are the lynchpin to fair initial reimbursement and have been used to obfuscate plan underpayment for far too long. The sooner the Fifth Circuit’s decision is implemented, the sooner the NSA and the IDR process can get back on track, protecting patients, ensuring the sustainability of medical practices, and leading to durable in-network contracts.

From there, Congress should pass H.R. 4710/S. 2420 and the Tri-Departments should end pervasive and predatory non-compliance with the NSA’s timely payment requirements, cracking down on health plans that choose to ignore binding arbitration awards in knowing and willful violation of the law.

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-Patrick

Gentle Reader,

One might be forgiven for believing the great debate has already been settled. The discourse has been most animated, after all, on matters of volume and velocity. How many cases. How long they linger. Whether the machinery of adjudication can keep pace with the ambition of its design.

These are tidy questions. Respectable questions. But they are not the most interesting ones.

Because beneath the ledgers and timelines, a quieter narrative has begun to circulate. Not in formal reports, but in the corridors between them. In the follow ups. In the polite inquiries that arrive weeks after a decision has already been rendered.

Providers are winning, and still not getting paid. The payers are singing another anthem, united in writing another path forward.

Industry estimates now point to hundreds of millions of dollars in awarded claims that remain unpaid. Not under appeal. Not overturned. Simply… unfulfilled. Suspended somewhere between determination and delivery, as though the final act of the process were optional rather than implied.

Which invites a rather delicate question: If a system produces winners, but does not reliably produce payment, what precisely has been resolved?

The Independent Dispute Resolution process was introduced with admirable clarity of purpose. A structured forum. A neutral arbiter. A binding decision. A protected patient experience. A means, at last, of replacing protracted negotiation with something more orderly, more predictable, more fair.

And after 3 years of adjustments, these opening movements perform quite well. Cases are submitted. Evidence is considered. Awards are issued. Value is, in fact, determined.

But it is in the final movement, the one that follows the applause, where the composition begins to lose its discipline.

For once a determination is made, the system steps back. The burden of execution returns to the very parties whose incentives necessitated arbitration in the first place. And it is here, in this quiet transfer of responsibility, self-enriching behavior reasserts itself.

Payment timelines lengthen. Follow ups accumulate. What was meant to be a resolution begins, almost imperceptibly at first, to resemble a continuation, only now with more paperwork and less certainty.

And then, inevitably, one notices the asymmetry.

Providers operate within a regime of well-defined obligation. Even modest missteps can carry consequences, often in the range of ten thousand dollars per patient when enforced. The expectation is clear. Accuracy is not merely encouraged. It is required, and deviations are not without cost.

Payers, by contrast, are afforded a more flexible posture once an IDR determination is made. There is no equivalent, time bound enforcement mechanism that compels payment within a defined window. No automatic penalty that attaches to delay. No structural consequence that mirrors the discipline applied elsewhere in the system.

One side operates under defined penalties. The other, under optionality. And optionality, as it so often does, becomes strategic.

For even after an award has been issued, the matter does not always conclude. Claims may be reprocessed. Patient responsibility recalculated. Adjustments introduced that, while technically compliant, have the practical effect of reshaping the financial outcome.

The decision, one observes, remains intact. The economics, however, are subject to revision.

There is no need to assume ill intent to understand this pattern. It is sufficient to recognize the incentives at play. In a system where delay carries no immediate consequence, delay becomes a rational choice. Cash is retained. Timelines stretch. And a certain percentage of claims, through fatigue or pragmatism, are simply not pursued to their logical end.

Even the capital meant to support resolution does not always move with the urgency of the decision itself. Administrative fees and arbitration costs, held in what functions as escrow, are not consistently returned on timelines that reflect a system designed for clarifying finality.

In private conversations, concerns are beginning to surface about the handling of these funds at scale, with some suggesting that material sums may be sitting in limbo longer than intended. Whether operational backlog or something more structural, the effect is the same. Capital that should reinforce trust in the process instead introduces a second layer of uncertainty.

At a certain scale, delay begins to resemble something more than timing. And so the process completes, at least in theory. The outcome is known. The record reflects a resolution. Yet justice is not concluded.

Over time, such patterns have a way of shaping behavior. Smaller providers, already constrained, begin to question the value of engagement. Larger organizations grow selective in their pursuits. The theoretical promise of IDR begins to diverge, ever so slightly at first, from the cash that ultimately arrives.

And in that divergence, one finds the beginnings of a more structural concern.

For a system that determines value but does not ensure its delivery is not, in the strictest sense, resolving disputes. It is extending them under more formal terms, as an abandonment of the rule of law.

Even as policymakers, including physician legislators such as Greg Murphy, have devoted considerable effort to refining how IDR decisions are rendered, far less attention has been given to what becomes of those decisions once they are made.

It is perhaps in that omission that the system reveals its most telling characteristic. Adjudication has been defined with precision. Enforcement, rather less so. The rules describe how decisions are reached, but remain curiously understated on how those decisions are to be carried through.

In the absence of such structure, the market does what markets invariably do. It optimizes. Not for fairness. For advantage.

Which leaves regulators and policymakers with a question that is at once simple and rather consequential.

Is the purpose of this system to render decisions, or to ensure that those decisions carry respect? Because at present, the distinction is not merely academic. It is operational. And increasingly, it is financial.

The remedies themselves are not especially mysterious. Payment following an award could be automatic, governed by clear and enforceable timelines. Delays could carry consequence proportionate to their impact. Escrow processes could be bound by defined service expectations. Transparency could extend beyond the outcome of disputes to include adherence to those outcomes.

Such measures would not alter the spirit of the system. They would complete it. Until then, we remain in a rather peculiar arrangement. Where disputes are resolved on paper. But not always in practice.

And where victory, for many, is less a conclusion than an invitation to begin again yet another administrative task. One suspects the market will not remain so patient indefinitely.

Yours, in equal parts curiosity and concern,

Larrian

#IDR_Reform, https://www.congress.gov/bill/119th-congress/house-bill/4710

Although consensus remains out of reach for now, we made progress toward that goal. The missing piece of the puzzle is an agreement on the premise - an acknowledgement between opposing parties that the facts are the facts and that the consensus to be reached is about the best way of accomplishing a shared goal. Until we can agree on the facts, consensus will remain frustratingly out of reach.

A significant roadblock on the path to consensus is the insurance industry’s argument that the NSA’s arbitration process (known as Independent Dispute Resolution, or IDR) is deeply biased in favor of providers, creating a “gold rush.” This framing would be compelling, except that it’s entirely unsupported by the data and doesn’t account for the insurer’s own failures in IDR. I’ve already addressed the volume and outcomes myths, which undermine the “gold rush” argument. Both articles are relevant to today’s analysis. I suggest reading those for additional context.

If “80% of success is just showing up,” the insurance industry’s lack of success may have something to do with its failure to show up to IDR over 30% of the time.

Using publicly available data, I’ll walk through one of the most significant drivers of insurer losses in IDR — and it has nothing to do with conflicts of interest.

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The IDR process

IDR is unique to the NSA. It incorporates aspects of arbitration from sources like Major League Baseball and the Federal Arbitration Act, but despite these influences, IDR is its own separate and distinct mechanism purpose built for the NSA. Congress explicitly designed the process to be binding. It’s also not subject to judicial review, which means a court can’t overturn or invalidate decisions except in a few narrow circumstances incorporated from the Federal Arbitration Act. The process uses “baseball-style” arbitration, in which each party submits only its last-best offer for consideration. The arbitrator must then select one of the two offers — it can’t split the difference or choose a different amount.

For its part, the arbitrator, usually referred to as the Independent Dispute Resolution Entity (IDRE), is tasked with reviewing whether or not a dispute is eligible for the process and selecting the offer that best represents an appropriate out-of-network payment.

Both the arbiter and the disputing parties are also required to sign an attestation affirming that no conflict of interest exists between the parties and the IDRE. This requirement has existed since the very first days of the IDR process, and falsifying the attestation is and always has been illegal. It’s true that IDREs only get paid on disputes that are found to be eligible, but CMS created a process to invalidate determinations that should have been found ineligible and requires IDREs to forfeit their fees if they got it wrong.

So if related-party bias and fees aren’t driving lopsided arbitration results, what is?

Insurers routinely fail to participate in IDR

The most recently available data on IDR usage comes from the Q2 2025 IDR Public Use Files (IDR PUFs). These highly detailed files are published roughly biannually by the Centers for Medicare and Medicaid Services (CMS) and are broken down by calendar quarter. The files provide line-item-level information about disputes resolved through IDR, including the names of the initiating party, non-initiating party, which party prevailed, and, importantly for our purposes, whether the prevailing party was chosen based on merit or by default (i.e., if their opponent failed to submit an offer). A supplemental anonymized file provides the actual dollar amounts offered by the insurer and provider for each dispute, along with which offer was selected. Together, the data reveal that high rates of insurer default and frequent extreme low-dollar offers are key driving forces behind insurer losses in IDR.

During Q2 2025, IDREs resolved 1,475,971 individual line items and services. It’s important to note that each dispute contains an average of about 2.4 line items, meaning there were roughly half as many disputes (616,020) as there were individual line items. Insurers prevailed in 178,728 line items, for a win rate of about 12%. Conversely, insurers lost on 1,297,243 line items, or 88%. Of those losses, insurers lost by default 352,327 times — a default rate of 27%. Even more striking, 137,643 (9%) of insurer losses involved insurer-submitted offers of $1 or less. It’s crucial to understand that offers submitted during arbitration are not additive. The offer being made is not what the insurer is willing to pay in addition to what they’ve already paid; it is the total amount they believe the service is worth. When an insurer offers $1 for an emergency medical claim requiring a high level of medical decision making, it’s valuing the care the physician provided at a total of $1.

When an insurer submits an offer of $0 (which they did in 114,618 (8%) of their losses during Q2 2025), they are suggesting that the physician should go completely uncompensated for the care they provided. Taken together, default decisions and offers of $1 or less made up 36.3% of insurer losses. This lack of meaningful participation effectively caps the insurer’s win rate at no more than 64%, assuming a perfect 100% win rate for the remaining line-items.

Even this doesn’t tell the whole story.

There is one additional piece of non-public data we can evaluate: the rate at which insurers submit evidence (any evidence at all) in support of an offer. Each IDR determination is accompanied by a standard determination explanation form. This form conveys key pieces of information to the disputing parties about how a dispute was resolved, including a grid that shows what evidence was provided by each party in support of its offer. For example:

In the example above, the initiating party (the provider) submitted evidence related to four of the six categories, while the non-initiating party (the insurer) only submitted evidence related to the “additional information” category. The insurer also submitted an offer of just one penny.

Using Optical Character Recognition (OCR), HaloMD reviewed and cataloged each and every dispute resolution form in which we represented the prevailing party for CY2025, totaling 619,238 line items. After excluding default awards and insurer offers of $1 or less (to prevent double-counting) we tallied the number of times the insurer provided supporting information for at least one category.

Ultimately, we found that insurers failed to provide ANY supporting information in 185,704 (30%) of the disputes they lost against the clinicians we represent. In those disputes, the “non-initiating party” column contained zero “X’s,” signifying the insurer did not submit evidence to support its offer 30% of the time.

Chickens come home to roost

Ultimately, between default awards (27%), insultingly low offers (9%), and a stunning failure to support their offers (30%), insurers only have a chance at success in about 44% of IDR disputes. If you sit on the sidelines for more than half the game, you can’t get upset when someone else is named MVP.

Rather than take accountability, the insurance industry announced this week that it’s spending “seven figures” on a new ad campaign blaming the arbiters for their failures. The Coalition Against Surprise Medical Billing (CASMB), a coalition organized through America’s Health Insurance Plans (AHIP), is rolling out the $1m+ ad campaign inside Washington D.C. and targeting policymakers.

CASMB’s ad uses anthropomorphic puppets waiting for their literal day in court; the cunning and deceptive foxes represent the villainous health care providers, while the classically vulnerable and good-intentioned insurance industry is cast as a pair of hens. The metaphor is completed when the judge, revealed to be a fox himself, takes his seat at the bench.

Lack of reputational self-awareness aside, a more appropriate metaphor might be an arsonist blaming the firefighters for allowing their house to burn down. They’ve damaged the process, now they’re running ads to claim they’ve been harmed by it.

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This logic is deeply flawed. At best it’s misleading, but more likely, it’s intentionally deceptive. In reality, insurers decide how much to pay for NSA covered care the vast majority of the time.

If you haven’t done so already, please read my previous post on IDR utilization before going further. Understanding the IDR volume issues raised there is helpful context.

Relativity’s Role in Assessing IDR’s Impact

Everything is relative; understanding relativity within a system is an essential part of assessing how changes within that system will affect it as a whole. Take for example, the question of the IDR process’ impact on the overall cost of care and health insurance premiums, particularly whether the NSA is achieving cost-savings (at the systemic level, relative to actual pre-NSA baselines). In order to effectively assess this question, a few threshold questions have to be sufficiently answered:

1. What is the volume of disputed claims (i.e., claims that are resolved through IDR), relative to the volume of claims that could be disputed?

2. What is the volume of claims subject to the IDR process (both claims that could be disputed and those that actually are), relative to their in-network counterparts and commercial claims broadly?

3. What effect has the NSA had on the total amount paid for disputed claims, undisputed claims, and in-network claims?

4. Taking into account the relative volume considerations raised in 1. and 2. and the cost implications of 3., what impact might the NSA have on medical costs?

In this case, the commercial healthcare market is the “system” and the NSA (including its IDR process) are the “changes within the system” that we’re trying to assess; ultimately, the impact on the cost of care and associated health insurance premiums.

Today’s article will start to examine these questions, focusing first on understanding relative volumes. We’re building the foundation on which we can ultimately assess the law’s overall outcomes and cost impact.

The Relative Volume of Disputes

The most readily available source of relativistic data on the IDR process and claims volume is survey information published by America’s Health Insurance Plans (AHIP) and the Blue Cross Blue Shield Association (BCBSA). Their most recent survey, published in October 2025, contains much of the information necessary to contextualize IDR volume within the larger commercial insurance system (ignore for now the survey’s nonsensical assertions regarding dispute eligibility, for which they offer zero evidence. I’ll confront this directly in a future article).

According to AHIP/BCBSA’s survey data, which covers CY2025, about 19.7 million commercial claims were subject to the NSA and could have been resolved through the IDR process. Of those 19.7 million claims, about 1.23 million were actually submitted to the IDR process. In other words, only about 6.2% of claims that could have been submitted actually were submitted to IDR.

To find the relative volume of claims resolved through IDR however, we have to further remove claims that were submitted to, but ultimately not resolved by, the IDR process. The survey data shows about 17% of disputes were found ineligible, which brings the total number of claims going through the IDR process to 1.02 million, or 5.2% of all potential claims.

Finally, only disputes that are decided in favor of the healthcare provider (i.e., a physician, facility, or air ambulance) typically result in a meaningful increase to the payment amount owed by the insurer, so let’s further remove instances in which the insurer is the prevailing party. This is where the insurers’ “unfairness” argument comes in, as in 2025, insurers were chosen by independent arbitrators as having submitted the more reasonable payment offer only 15% of the time. This brings the total number of disputes resulting in an IDR determination greater than the insurer’s initial payment to about 868,000. This means insurers were required to make an additional payment as a result of the IDR process for just 4.4% of claims subject to the NSA.

The real insurer win rate is over 95%.

The Danger of Ignoring Context

The health insurance industry’s lobbyists and communicators want policymakers to believe IDR is broken. It’s a process they opposed from the beginning, instead demanding a take-it-or-leave-it benchmark of their own calculation (the QPA). They think if they can convince enough policymakers something is wrong, they can undo the IDR process, or at least render it useless by making their unaudited and distorted QPA calculations the mandatory outcome. The echoing narrative they’ve latched onto is that IDR is overused and overwhelmingly biased against them.

Fortunately, the data underlying their narrative proves the opposite: IDR is used judiciously, initiated for only about 6% of relevant claims. Rather than demonstrating bias, providers win 85% of the disputes they do initiate because they typically bring disputes they know they can win - real underpayments in need of correcting. A 50/50 win rate, which the insurers have identified as the hallmark of fairness, would instead signify that 50% of disputes shouldn’t have been initiated in the first place. A district attorney with a conviction rate as low as 50% would be (rightfully) investigated for a pattern of wrongful prosecution.

In attempting to use IDR volume and the provider win-rate as evidence that the process is being abused; insurers have instead demonstrated that it’s not… at least not by providers.

Make no mistake, the NSA is in need of improvement, but changes should focus on streamlining the process and enforcing compliance, not making concessions to health insurance companies that just don’t like the law. The IDR Operations Rule should hopefully solve most of the process complexity issues, and increased regulatory oversight, along with passage of the NSA Enforcement Act, H.R. 4710/S.2420, should solve issues with insurer noncompliance. The sooner each goes into effect, the better.

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A few years ago, in Health Affairs Forefront, I argued that one of the most persistent implementation challenges for the NSA has been volume — not because the law is flawed, but because the methodology the federal government used to estimate its use was. This is not my subjective opinion, but rather, objective fact. Avoidable mistakes in methodology led to a dramatic underestimation of how many disputes the system would actually need to process.

That miscalculation continues to shape the debate today. It’s been repeated by well-intentioned observers, but weaponized by disingenuous opportunists.

If we want to improve the functionality of the NSA and the IDR process, we have to start by revisiting how the tri-departments — Health and Human Services, Labor, and Treasury — arrived at their original projections. There will be math, but stick with me.

A Modeling Error That Built the Backlog

Before the NSA went into effect, the tri-departments estimated that the federal IDR system would see roughly 17,000 disputes annually.

In reality, the system received 489,000 disputes in its first 14.5 months — an annualized run rate of roughly 405,000 disputes per year. It’s currently on track to surpass 2 million annual disputes.

That is not a marginal miss. It is an orders-of-magnitude error. The question is, “why?”

The answer is, the departments based their estimate entirely on New York’s IDR experience. They took the approximately 1,000 annual disputes observed by New York and scaled them nationally by calculating New York’s share of the employer-sponsored and privately insured population — roughly 5.7 percent of the national total — yielding the 17,000 figure.

So, what’s wrong with this approach? First, the Departments failed to differentiate between New Yorkers enrolled in state-regulated plans (and therefore subject to the state’s balance billing law) and those with plans regulated by the federal Department of Labor (which cover the majority of Americans and are NOT subject to state law), when determining the denominator for the volume estimation. But much worse, the methodology ignores the fact that New York’s law was not an apples-to-apples model.

New York’s law required the use of FAIR Health data as the benchmark for out-of-network reimbursement and effectively carved out emergency medicine disputes by tying those out-of-network payments to an independent external standard known as “usual and customary” rates. The federal NSA did not adopt that structure. Instead, disputes across all relevant medical specialties, including emergency medicine, are resolved by an independent arbitrator that must consider a range of factors when making its decision.

That difference matters.

New York’s system structurally eliminated disputes from the specialty most likely to result in an out-of-network visit: emergency medicine. The federal system does not, and unsurprisingly, over half of all federal disputes involve emergency medicine. Forget apples-to-oranges, this is more like comparing apples-to-omelets.

The Model that was Ignored

Texas offered a more relevant model, and usage data was readily available.

Texas’ balance billing law had:

• An arbitration process,

• No carve-out or anchor for emergency medicine,

• A structure more generally analogous to the federal NSA.

In its first year after enactment in 2020, the Texas Department of Insurance received nearly 49,000 dispute resolution requests. That law applied to approximately 5.8 million Texans.

Let’s walk through the math, using the exact same underlying methodology used by the Departments, but substituting New York’s data for Texas’. Texas’ law applied to about 5.8 million Texans, who were enrolled in state-regulated insurance plans. At the time, the national employer-sponsored and privately insured population was approximately 183 million people, so:

5.8m covered Texans ÷ 183m insured nationally = .0317, meaning Texas’ experience represents about 3.17% of the relevant national insured population

49,000 disputes ÷ .0317 = 1,546,000 estimated annual disputes

That is the volume the federal government might have anticipated had it selected Texas as its baseline rather than New York.

Instead, the system was built for 17,000.

The Consequences of Underestimating Volume

When a system is built for 17,000 disputes and receives hundreds of thousands, predictable failures follow:

• Misaligned administrative cost projections

• Uninformed policy making

• Eligibility delays

• Backlogs are measured in months, not days

These failures are then mischaracterized as the result of “abuse” rather than modeling error. Volume has become a controversy. But the volume was predictable.

Overall Impact

The debate around the IDR process has often framed high volume as evidence of provider overuse or something even more nefarious.

But if the system was underbuilt from the beginning because it relied on a structurally suppressed model, then volume is not an aberration; it’s something we can forecast.

Texas should have been the focus because:

• It applied to all of the same specialties as the NSA

• It utilized an IDR process structured similarly to the NSA’s

• Usage data was readily and publicly available

The proposed reforms to strengthen IDR infrastructure — including enhanced eligibility determination and improved portal transparency — are necessary. But they also reflect a recognition that the original capacity assumptions were flawed.

We cannot fix what we misdiagnose. Those who continue to rely on a misdiagnosis to treat a problem should be viewed with significant skepticism, as they are either uninformed or intentionally attempting to deceive.

If we continue treating volume as abuse rather than as a foreseeable outcome of flawed modeling, we risk undermining the very reforms the NSA created.