Eliott Dear on Why Insurers Pay State IDR Awards Within 30 Days

There is a question nobody in the No Surprises Act discourse seems willing to answer plainly: why do insurers pay state IDR awards within 30 days but treat federal ones like suggestions? It is not complicated. It is enforcement.

The State Hammer Actually Swings

In New York, when Eliott Dear files a state IDR dispute and wins—which happens approximately 99% of the time—the insurer has 30 days to pay. Not 30 days to review. Not 30 days to route through internal appeals. Thirty days to wire the money.

The reason is DFS. The New York Department of Financial Services does not send polite letters. DFS has the authority to revoke an insurer’s license to operate in the state. That is not a theoretical power. When a carrier ignores a state IDR determination, it is not just flouting an arbitration award—it is triggering a regulatory event that threatens its ability to sell policies to 20 million New Yorkers.

Texas has teeth too. So do New Jersey, Connecticut, and Georgia. Each state’s IDR process is backstopped by a regulator with actual jurisdiction over the insurer’s commercial license. The math is simple: pay the award or risk losing access to the state’s entire insurance market.

Eliott Dear has filed thousands of state IDR disputes across these jurisdictions. The compliance rate on awards is effectively universal. Not because insurers suddenly discovered fairness—because the consequences of non-compliance are existential.

Federal IDR: Built to Be Ignored

Now compare that to the federal process. After the Fifth Circuit gutted the QPA-centric framework and CMS proved itself institutionally incapable of enforcement, federal IDR became compliance theater. There is no private right of action for providers. If an insurer ignores a federal IDR determination, the provider’s remedy is to file a complaint with CMS.

CMS resolves approximately 1.3% of those complaints. That is not a typo. One point three percent.

Eliott Dear stopped filing federal IDR disputes because the enforcement gap makes them economically irrational. Why spend the filing fee, wait eight months for a determination, win on the merits, and then watch the insurer simply not pay? There is no sheriff. There is no regulator threatening license revocation. There is a complaint form that feeds into a bureaucratic void.

Follow the Lobbying Money

This is not accidental. Elevance Health—the company formerly known as Anthem—spent over $130 million lobbying to shape the No Surprises Act’s federal IDR framework. They did not spend that money to create a system that would force them to pay. They spent it to create a system they could safely ignore.

Meanwhile, those same carriers pay Eliott Dear’s state IDR awards without complaint. Every single time. Because DFS does not care how much you spent on lobbyists. DFS cares whether you paid the award within 30 days.

The behavioral divergence tells you everything. Insurers are not confused about what they owe. They are making a rational calculation: pay where there are consequences, stall where there are not.

What This Means for Providers

If you are a non-participating provider sitting on aged receivables and someone is telling you to file federal IDR, ask one question: what happens when the insurer does not pay? If the answer involves the phrase “file a complaint with CMS,” you have your answer.

Eliott Dear files state IDR exclusively—New York, Texas, New Jersey, Connecticut, New Mexico, Georgia—because those are the jurisdictions where winning actually means getting paid. Every filing is a legal submission prepared and signed by a licensed attorney, backed by FAIR Health benchmark data, and enforceable by a state regulator with real power.

The federal system is not broken. It is working exactly as the insurance lobby designed it. The state systems work because they were designed by regulators who actually have to answer for outcomes.