Critical Care: 3.47× the Insurer's Own Benchmark
In the last quarter of 2025 the median prevailing offer in critical care disputes was 3.47× the qualifying payment amount — the figure the plan itself calculated. Across the second half of 2025, certified IDR entities decided 24,514 payment determinations in this category, covering 35,690 items or services.
What the Federal Data Says About Critical Care
How to read this. The qualifying payment amount is the plan's own calculated benchmark — generally the median contracted rate for the service in the geographic area. A median prevailing offer of 3.47× QPA means that in half of the decided disputes in this category, the offer the certified IDR entity selected was at least 3.47 times what the plan had calculated. It is a measure of the gap between the plan's benchmark and what an independent entity found defensible. It is not a prediction, a guarantee, or an average recovery for any particular practice, and it does not include disputes that were found ineligible or that closed before a determination. CPT range for this category: 99291–99292 (critical care, first hour and each additional 30 minutes).
Source: CMS, Federal Independent Dispute Resolution Process — Supplemental Tables, Q3 and Q4 2025, Table 14 (prevailing offers relative to QPA by specialty) and Table 12 (payment determination outcomes). Published by CMS here.
Why Critical Care Claims End Up Out of Network
Critical care sits at the intersection of the two protections in the statute. Care that begins as an emergency remains covered as emergency care through stabilisation, and hospital-based intensivist services at an in-network facility fall under the facility-based protections. In both cases the patient is shielded and the physician's recourse against the plan's payment is federal IDR.
Critical care time is billed by duration — the first 30–74 minutes, then each additional 30 minutes — and documentation of that time is what a certified IDR entity will look for when weighing the offers. Groups that dispute critical care claims successfully are almost always the ones whose time documentation is unambiguous.
Deciding Whether a Claim Is Worth Disputing
Three things determine whether a specific claim belongs in federal arbitration, and none of them is the specialty itself.
1. Is the claim eligible?
15.0% of disputes closed in January–September 2026 were found ineligible, down from 18.7% in the second half of 2025 but still about one in seven — the single largest source of wasted effort in this process. Eligibility turns on whether the item or service falls under the federal protections rather than a state process, whether open negotiation ran its full 30 business days, and whether the dispute was filed within the four-business-day window that follows. Getting this wrong costs the fee and the claim.
2. Does the arithmetic work?
Since June 11, 2026, the administrative fee is $15 per party per dispute, down from $115. The certified IDR entity fee is set within a range published annually by the Departments and is paid by the non-prevailing party. Against those costs, the relevant question is the gap between the plan's payment and a defensible value for the service — and the federal data shows that gap by claim size is largest on smaller claims, not larger ones.
3. Can the claims be batched?
Qualifying claims may be submitted together in a single dispute. For a critical care practice generating similar claims against the same plan, batching is usually what turns a marginal economic case into a clear one.
We review claims against these three tests before anything is filed, and we are paid only out of what is actually recovered. If the claims do not clear the tests, we say so.
Common Questions About Critical Care Claims
What did federal arbitration award for critical care claims?
Across 24,514 payment determinations in the second half of 2025, the median prevailing offer in this CPT category was 3.47× the plan's qualifying payment amount, per CMS Table 14. That is a median across every determination in the category, not a prediction for an individual claim, and the multiple falls as the claim gets larger — from 5.22× below $100 to 1.69× above $10,000.
Which CPT codes does this cover?
CMS groups these determinations under 99291–99292 (critical care, first hour and each additional 30 minutes). The category accounted for 1.9% of all 1,297,738 payment determinations the Departments reported for the second half of 2025.
Why do these claims end up out of network in the first place?
That is the part the numbers do not answer, and it is set out above for this specialty specifically. What the published data does show is that the process is used almost entirely by the provider side: of 1,372,563 disputes initiated nationally in the second half of 2025, health plans and issuers initiated 177.
What stops a claim in this category from reaching a decision?
Eligibility, not the merits. 15.0% of disputes closed nationally in January–September 2026 — about one in seven — were found ineligible and never reached a determination (18.7% in the second half of 2025), most often the wrong forum, a missed window, or a service the No Surprises Act protections do not cover. The window to initiate is four business days, beginning on the 31st business day after the open negotiation period started.