OON-IDR

Out-of-Network IDR - Win the Dispute Before it Starts

In the No Surprises Act’s Independent Dispute Resolution (IDR) process, the arbitrator’s decision hinges on one thing: who brings the most credible, concrete evidence of market-consistent reimbursement rates.  FlexPoint puts that  power squarely in your hands.

EOBs:  Irrefutable Evidence in IDR Arbitration

 

When payers challenge your rates in IDR, they rely on incomplete datasets, stale MRFs, and self-reported benchmarks.  FlexPoint counters with actual EOB documents — real claims, stripped of PHI, sourced directly from patients.  These are not estimates.   They are the are the actual negotiated rates paid by insurers to providers, specific to insurer product, specific to Tax ID / NPI, and dated within the last 30 days.

Arbitrators are required to weigh Qualifying Payment Amounts (QPA) against credible market data.  There is no more credible market data than an EOB.

Why This Matters in the IDR Process

 

Certified and submittable.  FlexPoint delivers actual EOB documents you can submit directly as exhibits in your IDR filing — not summaries, not reports derived from data.  The source document itself.  

 

Granular by insurer and reimbursement methodology.  EOBs capture how payers actually pay — not what they claim to pay. 

 

Shifts leverage to providers.  When your evidence is more current, more specific, and more verifiable than the payer’s, the arbitrator takes notice.  FlexPoint clients enter IDR with a structural advantage.  

When MRFs fail you, EOBs don't.

Machine-Readable Files are often incomplete, outdated, or missing entirely.  In IDR — where every dollar counts — FlexPoint fills those gaps with EOB-derived datasets that are just as actionable and far more defensible.  Whether you’re validating existing benchmarks or building your rate evidence from scratch, FlexPoint ensures you never walk into arbitration empty-handed.  

Samples:

Anesthesia

FlexPoint Health — Anesthesia EOB Illustration

Two patients. Two procedures. One contractual rate — proven.

The EOBs below are a digital representation for illustration purposes only — created to show exactly what FlexPoint’s data reveals. In practice, FlexPoint delivers scanned copies of the actual underlying patient EOBs, procured directly from patients and stripped of all protected health information (PHI) prior to delivery.

These two claims — different patients, different procedures, same anesthesiologist group — show an identical conversion factor of $66.00 per unit. That is the contractual rate. Not an estimate. Not a model. The actual rate the insurer pays — confirmed across multiple EOBs and delivered to you as irrefutable evidence.

Nationwide Health Plan
PPO Plus — Group Coverage
Explanation of Benefits
This is not a bill
Member
REDACTED
EOB date
04/28/2026
Claim #
CLM-2025-00931847
Provider
Anesthesia Associates of America, PC
Specialty
Anesthesiology
NPI
9876543210
DOS
04/10/2026
CPT Modifiers Description Base units Time units Total units Allowed
00630 AAP1 Anesthesia, lumbar spine 10 14 24 $1,584.00
Totals 24 $1,584.00
AA — Anesthesiologist personally performed
P1 — Normal healthy patient
Conversion Factor
Reimbursement methodology
$66.00 / unit  Conversion factor
24 units × $66.00 = $1,584.00  |  1 unit = 15 min
Plan type
PPO
Commercial group
Billed
$3,720.00
Contractual adj: $2,136.00
Total allowed
$1,584.00
57.4% adj off billed
🔒 PHI removed — Sample document by FlexPoint Health Research, LLC
Nationwide Health Plan
HMO Select — Group Coverage
Explanation of Benefits
This is not a bill
Member
REDACTED
EOB date
05/14/2026
Claim #
CLM-2025-01047583
Provider
Anesthesia Associates of America, PC
Specialty
Anesthesiology
NPI
9876543210
DOS
04/29/2026
CPT Modifiers Description Base units Time units Total units Allowed
00402 AAP1 Anesthesia, reconstructive breast 6 20 26 $1,716.00
Totals 26 $1,716.00
AA — Anesthesiologist personally performed
P1 — Normal healthy patient
Conversion Factor
Reimbursement methodology
$66.00 / unit  Conversion factor
26 units × $66.00 = $1,716.00  |  1 unit = 15 min
Plan type
HMO
Commercial group
Billed
$2,080.00
Contractual adj: $364.00
Total allowed
$1,716.00
17.5% adj off billed
🔒 PHI removed — Sample document by FlexPoint Health Research, LLC
✓
Conversion factor confirmed: $66.00 / unit
Two different patients — two different procedures — one consistent contractual rate. This is what FlexPoint EOB data proves.
FlexPoint Health Research, LLC  |  For illustration purposes only. All data is fictitious. No PHI is contained herein.
© 2026 FlexPoint Health. All rights reserved.

Emergency Medicine

FlexPoint Health — Emergency Medicine EOB Illustration

Same payer. Same physician group. Two visit levels — and exactly what the insurer pays.

The EOBs below are a digital representation for illustration purposes only — created to show exactly what FlexPoint’s data reveals. In practice, FlexPoint delivers scanned copies of the actual underlying patient EOBs, procured directly from patients and stripped of all protected health information (PHI) prior to delivery.

These two claims show the contractual allowed amount as a percentage of the CMS 2026 National Medicare rate — making it immediately clear how this insurer’s contract compares to the federal benchmark at each visit level.

Nationwide Health Plan
PPO Plus — Group Coverage
Explanation of Benefits
This is not a bill
Member
REDACTED
EOB date
04/22/2026
Claim #
CLM-2026-00847291
Provider
Metro Emergency Physicians, PC
Specialty
Emergency Medicine
NPI
1234509876
DOS
04/08/2026
CPT Modifiers Description Billed Contractual adj. Allowed
99285 25 ED visit, high complexity (Level 5) $1,600.00 $1,035.00 $565.00
Totals $1,600.00 $1,035.00 $565.00
25 — Significant, separately identifiable E&M service
Allowed amount vs. CMS 2026 National Medicare Rate (99285)
Insurer allowed
$565.00
CMS 2026 National
$171.35
Insurer pays 329.7% of CMS 2026 National  |  $565.00 ÷ $171.35
% of CMS 2026 National
Reimbursement methodology
329.7% of Medicare  CMS 2026 National rate
$565.00 allowed  |  CMS national: $171.35  |  CPT 99285
Plan type
PPO
Commercial group
Billed
$1,600.00
Contractual adj: $1,035.00
Total allowed
$565.00
64.7% adj off billed
🔒 PHI removed — Sample document by FlexPoint Health Research, LLC
Nationwide Health Plan
PPO Plus — Group Coverage
Explanation of Benefits
This is not a bill
Member
REDACTED
EOB date
05/03/2026
Claim #
CLM-2026-00913847
Provider
Metro Emergency Physicians, PC
Specialty
Emergency Medicine
NPI
1234509876
DOS
04/19/2026
CPT Modifiers Description Billed Contractual adj. Allowed
99284 25 ED visit, moderate complexity (Level 4) $1,100.00 $710.00 $390.00
Totals $1,100.00 $710.00 $390.00
25 — Significant, separately identifiable E&M service
Allowed amount vs. CMS 2026 National Medicare Rate (99284)
Insurer allowed
$390.00
CMS 2026 National
$118.24
Insurer pays 329.8% of CMS 2026 National  |  $390.00 ÷ $118.24
% of CMS 2026 National
Reimbursement methodology
329.8% of Medicare  CMS 2026 National rate
$390.00 allowed  |  CMS national: $118.24  |  CPT 99284
Plan type
PPO
Commercial group
Billed
$1,100.00
Contractual adj: $710.00
Total allowed
$390.00
64.5% adj off billed
🔒 PHI removed — Sample document by FlexPoint Health Research, LLC
✓
Reimbursement methodology confirmed: ~330% of CMS 2026 National across both visit levels
Two different patients, two different visit complexities — the insurer’s contract consistently pays approximately 330% of the CMS Medicare benchmark. Only an actual EOB reveals this. This is what FlexPoint delivers.
FlexPoint Health Research, LLC  |  For illustration purposes only. All data is fictitious. No PHI is contained herein.
CMS 2026 National Medicare rates: 99285 = $171.35  |  99284 = $118.24  |  Source: CMS Physician Fee Schedule CY 2026
© 2026 FlexPoint Health. All rights reserved.