Let’s meet in the middle.

It’s one of the most reasonable sentences in business. It assumes both sides can give a little and settle on something fair.

The federal Independent Dispute Resolution (IDR) process, created under the No Surprises Act (NSA), doesn’t quite work that way. IDR is final-offer arbitration. That means an arbiter receives two monetary offers and picks one. No splits. No compromises.

Right now, transporters are winning these disputes. And it’s not close.

According to CMS data from the first half of 2025, providers, facilities, and medical transporters prevailed in roughly 88% of decided transport IDR payment determinations.

CMS also reports that in roughly 88% of payment determinations, the awarded amount came in higher than the qualifying payment amount, or QPA. The QPA is a health plan’s benchmark rate for similar services in that geographic area, calculated under federal rules.

This is happening against the backdrop of a $22 billion medical transportation market that remains largely unmanaged. Commercial plans often pay 500% to 700% of Medicare rates for air transport, bearing an outsized burden.

So health plans aren’t just losing. They’re often losing in amounts well above their own benchmarks.

Say a health plan’s QPA is $15,000 and its submitted IDR offer is $25,600. The transporter’s offer is $70,000. Only one number wins. In the first half of 2025, it was almost always the transporter’s. And that pattern has been consistent.

In a recent conversation, one Blue plan described having 490 air transports in a single year. Every one of them was out-of-network. Every one went to IDR. And the plan lost 95% of those cases. With 85% of ground and 75% of air transports occurring out-of-network, the volume of these disputes is staggering.

IDR was designed to give plans and out-of-network providers a structured way to resolve payment disputes and, most importantly, protect the patient from undue financial harm.

No Surprises. But a Predictable Pattern.

The No Surprises Act was designed to keep patients from getting caught in the middle of out-of-network billing disputes, including air ambulance transports. The legislation has been widely applauded and for certain constituents, it did have positive health or economic impacts. But the billing disputes didn’t disappear; they simply shifted from one healthcare stakeholder to another – in this case, the patients and health plans. Based on the data, most still haven’t found a pathway to arbitration success.

In most IDR cases, the core question is whether the price charged was reasonable for the service provided. However, medical transport layers clinical and operational judgment on top of that, which leaves room for additional documentation. Furthermore, the IDR process evaluates rates but lacks the resources necessary to truly dig into the mode of transport itself—leaving a massive blind spot. Was air transport really necessary, or would ground have worked? Was the billed service level accurate? Did the routing make sense? Answering those questions requires case-by-case clinical review—the kind most health plans aren’t staffed to perform. And it’s costing them.

Where Medical Transport IDR Cases Are Won and Lost

Transport IDR cases tend to come down to the same core questions. Health plans that lose consistently simply do not have the resources to match the 400+ page packets that counterparties (such as transporters) are submitting against them and the members they serve. The good news is that these are identifiable gaps, and when plans address them, outcomes shift. And when outcomes shift positively in any area of healthcare cost, the patient wins—plain and simple.

A large share of disputes hinge on whether the level of service billed is supported by the medical record. A claim may be billed at Advanced Life Support (ALS) or Specialty Care Transport levels due to the patient having had a stroke, for example. The run report, however—an industry standard and legally required document filled out by EMS crews at the conclusion of their time with the patient—may tell a different story about someone with stable vitals, no ALS-specific interventions performed, and routine handoffs. The stroke may have occurred ten days prior, with the patient stable for nine of those days. Despite the claim showing a stroke, the patient is actually stable and able to safely and effectively be transported via Basic Life Support (BLS).

Health plans that win these disputes systematically evaluate whether the billed service was actually performed and was medically necessary. The data suggests that payers who build a strong case on this point win 70–80% of ALS vs. BLS disputes.

The air-versus-ground question carries similar weight. Air transports and flight crews save lives. No one would ever question that. But air transport is expensive, and not every transfer involves the kind of time pressure that justifies it. In fact, most rotor transports could be safely and effectively completed via ground transportation with proper clinical review, representing up to 62% of the total savings opportunity.

When the record reflects a stable patient who could have been moved safely by ground, and the plan can explain why, it reframes the entire question.

Routing choices and urgency claims that don’t match the documentation also matter. It’s not unusual for a claim to read “emergent” while the record reveals the controlled transfer of a stable patient. That kind of inconsistency changes the tenor of a case and likely tips the scales toward the payer. But the onus is on the payer to invest the time and resources to investigate that information and build an argument around it.

Making a case about clinical appropriateness is only half the battle for health plans. The other half is a pricing argument grounded in the QPA and supported by market data that shows the provider’s charges are out of step with what similar services cost in that area.

Building that kind of dual capability in-house takes clinical expertise, transport-specific knowledge, and dedicated resources that most health plans simply don’t have today.

Breaking the Cycle, Before and After the Bill

There are two opportune times to mitigate IDR, and they occur both before and after a transport is executed. This is where Alacura’s expertise comes into play. Alacura turns medical transport from an unseen liability into a strategic lever.

On the front end, Alacura’s clinical team—a scaled team of ER physicians and flight-trained nurses—works in real time with sending physicians to assess each patient’s condition and determine the safest, most clinically appropriate mode of transport. When those decisions are clinically grounded and aligned with in-network insurance options, it eliminates any possibility of IDR down the road. Pre-authorized transports are not permitted to go to IDR.

On the back end, when cases do go to IDR, Alacura helps health plans build structured, evidence-based responses. That means reviewing run reports for service-level accuracy, evaluating whether air transport was clinically justified, analyzing routing and urgency claims against the documentation, and tying the clinical findings to a pricing argument anchored in the QPA. The goal is to make a clear, consistent case that’s easy for a decision-maker to follow.

With a national network of nearly 600 ground and over 100 air assets, Alacura achieves an average cost reduction of 30% to 40% for health plan clients, backed by a 4:1 value guarantee with fees at risk.

The Cost of Standing Still

Health plans without a transport IDR strategy are getting hit twice. First, there’s the immediate financial impact of losing an IDR case. With transporters winning roughly 88% of decided cases, plans are paying above their own benchmarks over and over again. Second, and more quietly damaging, every one of those losses feeds the data that shapes future QPA calculations and future IDR outcomes. Today’s inflated awards become tomorrow’s baseline. And the pattern of losing doesn’t just repeat—it compounds over time.

A better path for health plans—and the patients they serve—is to treat medical transport IDR as a serviceable area of healthcare. That means clinical reviews, consistent case development, thorough documentation, and a strategy built around winning—all without the scramble every time a new IDR date is set.

If your health plan is experiencing consistent losses from medical transport IDR, it may be time to build a more proactive transport-specific strategy. Alacura can help.

To learn more about Alacura, visit www.alacura.com. For a deeper discussion about IDR and how our team of experts can help, contact us at info@alacura.com.

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