Madison Law Firm PLLC represents out-of-network physicians, surgeons, and medical practices across New York in state IDR and federal No Surprises Act arbitration — recovering up to six years of underpaid claims. No recovery, no fee.
If your practice bills out-of-network and regularly accepts whatever the insurer decides to pay, you are leaving significant revenue on the table. New York law — and now federal law — give you the right to dispute inadequate payments through binding arbitration.
Surgeons operating at in-network facilities with OON status — including plastic surgeons, orthopedic surgeons, neurosurgeons, and general surgeons — routinely face systematic underpayment on claims that are clearly eligible for dispute.
NY IDR + Federal NSAAncillary providers cannot obtain consent waivers. You cannot balance-bill patients. IDR arbitration is your only path to fair reimbursement — and with an 85% provider win rate, it is a path worth taking.
Ancillary Provider RightsASCs servicing OON patients at in-network procedures face the same underpayment dynamics as physicians. Facility fees are separately disputable and represent some of the highest-value IDR claims.
Facility Fee DisputesDiagnostic specialists are among the most frequent IDR filers nationally. Your services are inherently ancillary — meaning patients cannot waive protection — and your claims are often batched efficiently for arbitration.
High-Volume BatchingEmergency services are protected under both NY state law and the federal NSA. We help EM groups dispute systematic underpayment across large claim volumes, using batching to reduce per-claim cost.
Emergency ServicesNew York's DFS IDR framework has no fixed statutory filing deadline, and claims you wrote off in recent years may still be arbitrable — with breach-of-contract litigation reaching back up to six years under CPLR § 213(2) for fully-insured plans. We review your claim history to identify revenue that has been systematically underpaid and can still be recovered.
Aged Claim RecoveryNew York's IDR process under Financial Services Law Article 6 and Insurance Law § 3241 is distinct from — and often more favorable than — the federal No Surprises Act process. Here is how it works.
The insurer receives your claim and issues an initial payment based on its Qualifying Payment Amount (QPA) — a 2019 median in-network rate indexed for inflation. This routinely undervalues OON services by 40–70%. Under NY law, the insurer must pay within 30 days (electronic) or 45 days (paper) under Insurance Law § 3224-a.
Before arbitration, both sides must attempt to negotiate. Under the federal NSA, this is a mandatory 30 business day window. Under NY state IDR, there is no prescribed negotiation period before filing, but good-faith correspondence strengthens your arbitration record.
For federal NSA claims, the initiating party must file within 4 business days after the open negotiation period closes. This deadline is strict and non-waivable. Missing it forfeits the claim. For NY state IDR, there is no fixed statutory filing deadline — and a parallel breach-of-contract action under CPLR § 213(2) can reach up to six years for fully-insured plans — providing significantly more flexibility.
This is "baseball-style" arbitration: the arbitrator must choose one side's offer — no splitting the difference. The provider and insurer each submit a single payment amount and a package of supporting evidence ("credible information"). The quality of this package is decisive. We build yours using FAIR Health UCR data, provider credentials, case complexity documentation, and prior payment history.
The IDRE (Independent Dispute Resolution Entity) selects one offer and issues a binding decision. Under NY IDR (FSL § 604), the arbitrator weighs ALL factors equally — including the 80th percentile of FAIR Health UCR charges, provider qualifications, case complexity, and market rates. No single factor is presumptive. Payment is due within 30 days of the determination. The losing party pays arbitration fees.
New York enacted the nation's first surprise billing law in 2015 — seven years before the federal No Surprises Act. The result: New York providers and patients have a dual-layer framework that is uniquely favorable.
Federal IDR has a 4 business day filing window after the open negotiation period. New York state IDR gives providers 3 years from the original payment to file a dispute. This means claims that were written off years ago may still be recoverable. (23 NYCRR 400 / FSL § 605)
Federal IDR uses the QPA (a 2019 median in-network rate) as its baseline. New York IDR requires arbitrators to consider the 80th percentile of UCR as calculated by FAIR Health — a benchmark that is systematically higher and more favorable to providers. (FSL § 604 / 23 NYCRR 400.7)
For fully insured New York health plans, NY state IDR and the federal NSA both apply. The law that provides more protection to the patient or provider prevails. You never lose a right — you can only gain additional ones by operating in New York.
Unlike federal IDR (where the QPA was originally presumptive), NY law expressly states that all FSL § 604 factors carry equal weight. Arbitrators must consider your qualifications, case complexity, market rates, and UCR data — giving skilled advocates significant leverage.
Every specialty has different IDR dynamics, different credible information requirements, and different QPA benchmarks. We know yours.
A practical guide for physicians and practice administrators on how to set up your billing, documentation, and claims workflow to successfully arbitrate OON disputes in New York.
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We had over two years of underpaid anesthesia claims that we'd essentially written off. The multi-year claim recovery window in New York was something we hadn't known about. Madison Law Firm recovered a significant portion of that revenue through IDR without any upfront cost to our practice.
As a plastic surgeon, the difference between what insurers initially pay and what FAIR Health 80th percentile says I should receive is substantial. Having legal representation that understands how to present our credentials and case complexity to arbitrators changed our recovery rate completely.
Our ASC had been accepting whatever United HealthCare paid on OON facility fees for years. We didn't know we had a right to dispute. The evaluation was free, the process was handled entirely by the firm, and the contingency arrangement meant there was no risk to start.
Free case evaluation. No upfront cost. No recovery, no fee. We review your claim history and tell you exactly what's recoverable.
Madison Law Firm PLLC · 579 Fifth Avenue, 2nd Floor, New York, NY 10017 · inquiries@madisonlawfirm.com · Attorney advertising. Prior results do not guarantee similar outcomes.