Health plans can't afford to treat independent dispute resolution as the place where out-of-network claims get settled. At TAHP, AMPS's Jake Weihrauch made the case for pricing claims so they never get there.

At the Texas Association of Health Plans conference, Jake Weihrauch from AMPS, joined the panel "Payment Integrity in Practice: Catching Errors, Repricing, and Reducing Waste." Moderated by Dr. Shyama Ghandi, Chief Medical Officer of Molina Healthcare of Texas, the session started from a simple premise: post-payment recovery is no longer enough to manage rising claim costs. The answer is to catch billing errors and questionable charges before payment, and to price out-of-network claims better from the start.

A tilted playing field

Jake applied that idea to what he called the single biggest driver of waste for most payers today: out-of-network claims under the No Surprises Act.

The federal data shows why. In the first half of 2025, providers initiated 99.9% of IDR disputes and won 88% of them, up from 77% in the first half of 2023 (Health Affairs). Volume keeps climbing, with nearly 1.4 million disputes filed in the second half of 2025 alone.

"The intent was to make sure providers are paid a fair and equitable amount," Jake told the room. "But when claims get into arbitration, providers are winning 88% of the time."

His conclusion: "We have to avoid the IDR altogether to make a real impact. And if a claim does go to IDR, we need a defensible pricing strategy that helps payers win more than they lose."

The policy view from down the hall

Jake wasn't the only one at TAHP sounding the alarm. In a session titled "No Surprises, New Problems," moderated by Pati McCandless of Maynard Nexsen, a panel of policy leaders laid out how far the dispute process has drifted from its intent. The panel included Rosemary Englert of AHIP, Josh Goldberg of Health Care Service Corporation, Melissa Bartlett of ERIC, Jack Hoadley of Georgetown University, and Katrina Daniel, former Chief Health Care Officer of the Teacher Retirement System of Texas.

They agreed on the starting point. The No Surprises Act has done its main job: patients are out of the middle of billing disputes. Englert called it "a well-intentioned law" that "has succeeded in its primary goal." The problem is what happened after courts struck down the rules that tied arbitration to in-network rates. Without that anchor, dispute volume and award amounts took off.

The numbers they shared tell the story:

• $22.4 billion in total IDR costs from 2022 through 2025, including $16.6 billion in 2025 alone, according to Hoadley's Georgetown research. Of that, $15.6 billion was paid above the in-network benchmark arbitration was meant to anchor to.
• About 90% of IDR-related costs are absorbed by self-funded employers, according to ERIC's September 2026 report, Employer Exposure Under the No Surprises Act.
• Real plans, real dollars. The City of San Antonio is facing a $40 million budget overrun, with one ER operator winning 99.6% of its disputes. New York's Empire Plan saw more than $200 million in added claims, the main driver of a roughly 10% premium increase for 2026. The 32BJ Health Fund paid $37 million in IDR determinations against $8 million expected, and the 1199SEIU funds paid $52 million above out-of-network rates across 4,919 disputes.
• About 4.8 million filings through 2025, against original expectations of 17,000 to 22,000 a year. Ten private equity–affiliated filers drove about two-thirds of them, and the filing fee has since been cut from $115 to $15, making each extra filing cheaper.
• 500+ people at HCSC now work on IDR alone. Plans get three business days to challenge a dispute's eligibility, and providers often file in large batches right before holidays. "You cannot hire people fast enough to keep up with this," Goldberg said.
• 2.5 points of a 9% premium increase at the University of Texas System's health plan are tied to IDR, Daniel said, with more than $120 million spent on disputes so far. At one point, a single freestanding emergency facility accounted for 5,800 of the plan's 6,400 disputed claims.

The panel was cautiously optimistic that Congress will act, with options ranging from restoring the in-network anchor to setting a payment benchmark. It also made the case that Texas' own state arbitration system offers a more stable model. But reform takes time, and every month the meter keeps running.

That is where Jake's panel picked up: what a health plan can do right now, before any fix arrives.

Start with the provider, not the claim

Jake's first point was that health plans can't wait for a dispute to start thinking about it. "Step number one is changing from a reactive state to a proactive one," he said. "And it starts with data."

That data usually shows a concentration problem. A small share of providers, often something like 10%, drives the large majority of out-of-network friction. The question is why, and the answer sits in each provider's history.

AMPS sorts providers by what they have billed in the past and how often they have objected to payments. Providers with a track record of accepting fair payment can be priced competitively with confidence. For providers with a history of disputes, math can run the other way. "We might actually suggest you pay more than you're paying today," Jake said, "just to keep that claim out of the IDR process."

Paying a little more up front can cost far less than an arbitration loss, plus the fees and staff time that come with it.

Defensible pricing is not a guess

Too many out-of-network strategies still rest on a flat benchmark or on what a peer plan seems to be doing in the region. Jake was blunt about that. "It's not a guess. It's not 300% of Medicare. It's not 'I heard this plan is doing it, maybe I'll try it.'"

A defensible price is built for the individual provider and the individual claim, grounded in that provider's own billing and acceptance history. That matters more every year. New out-of-network facilities keep opening, arbitration-focused intermediaries file disputes at scale, and the rules governing the process keep changing.

Without knowing the provider and the claim history, a plan has no solid basis for its price, and no strong position if the claim ends up in front of an arbiter.

Showing providers a mirror

Pricing well is only half the work. When a provider does push back during the open negotiation period, AMPS engages right away and explains exactly how the claim was priced, using the provider's own data.

"We're showing them a mirror of where they've been okay to accept in the past," Jake said.

Most of the time, that conversation resolves the claim before it ever reaches IDR.

The results reflect that pricing-first approach:

• 97% of disputes are resolved without going to IDR arbitration.
• 80% win rate for AMPS when a claim does go to arbitration.
• 99% pre-IDR resolution rate at one current payer client.

"When it goes to IDR, having the right documentation and a defensible strategy, we are winning 80% of the time," Jake said. That flips the national pattern, where providers win close to nine in ten disputes.

A tool, not the carpenter

Much of the panel focused on AI, and the speakers agreed: it is changing how claims get reviewed, but people still make the hard calls. Jake put it simply. "It's a tremendous tool to leverage, but it's a tool, not the carpenter." Data analysis can move faster, but complex payment decisions still need experienced people checking both the inputs and the outputs.

The takeaway for health plans

The IDR process was built to settle disagreements. For most payers, it has become one of the largest sources of out-of-network cost. Policy reform may come, but no plan can budget on it. Waiting for arbitration and hoping to win is not a strategy.

The plans getting ahead of it are doing three things:

1. Knowing their providers, including which ones are likely to dispute and why.
2. Pricing each claim with a defensible methodology grounded in that provider's own history.
3. Engaging quickly and transparently when a provider objects, so claims resolve before IDR.

To learn how AMPS helps health plans and TPAs keep out-of-network claims out of arbitration, contact AMPS at Sales@AMPS.com.