Eliott Dear: Why ER Physicians Get Paid 30¢ on the Dollar (and Where to Dispute It)

The number is real. Across commercial out-of-network emergency-medicine claims in 2025-2026, the median reimbursement Claims Assassins sees on initial-pay EOBs runs roughly 25 to 35 cents of every billed dollar. That is the 30-cents-on-the-dollar story emergency physicians describe.

Eliott Dear has watched this pattern across hundreds of EOBs. The structural causes are specific. So is the forum built to dispute them.

Cause One — Multi-CPT Downcoding

Carriers aggressively downcode complex procedure stacks. A patient who arrives with a complex facial laceration may have CPT 13132 and 13152 (complex repair) and 99284 (ER E/M, level 4) all properly billed. Carriers routinely pay only the highest-RVU code and zero on the others, citing bundling, NCCI edits, or coding-policy adjustments.

That practice is contestable. Each CPT carries independent medical-necessity documentation. The downcoding pattern is a direct contributor to the 30-cents-on-the-dollar number.

Cause Two — Carrier Bet on Non-Disputation

Carriers know that most non-par ER providers will not file IDR. The administrative threshold (FAIR Health benchmark pull, attorney-grade submission package, deadline tracking through to determination) is real. Carriers price their initial offers with that in mind. When most providers never file, the initial payment is the final payment on every claim nobody contests.

That is not theory. That is the industrial-organization math behind the initial-pay number on every EOB.

Where to Dispute It

State IDR is the forum. New York has its own process; Texas, Connecticut, New Jersey, Georgia, and New Mexico each have their own version. In New York, the benchmark is FAIR Health 80th-percentile UCR data for the same geographic locality. A state determination is binding, and the regulator that licenses the carrier stands behind the process.

Eliott Dear sorts the plan on every claim at intake, then files a full documented package for each state-eligible claim under his own bar number. On a 10% contingency model, filing is how the 30-cents-on-the-dollar gap gets contested for the cases that are state-IDR eligible.

Each package carries the FAIR Health benchmark pull, CPT-by-CPT medical-necessity documentation, and the attorney-signed submission, with every deadline tracked through to determination.

The 30 cents is the carrier’s initial payment. The lever is filing.