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?
Roughly one in five disputes initiated in 2025 was found ineligible — 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.