Eliott Dear: Why ER Physicians Get Paid 30¢ on the Dollar (and Why It’s a Solvable Problem)

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 25-35% of the physician’s billed charge. 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 recovery path.

Cause One — The QPA Floor

Under the No Surprises Act, commercial carriers anchor initial-pay rates to the Qualifying Payment Amount. The QPA is a median-in-network rate computed from the carrier’s own data. For emergency-medicine CPT codes (99281-99285 for E/M, plus the trauma-repair codes 12001-13160 and beyond), QPAs land 60-80% below historical FAIR Health 80th-percentile UCR data for the same geographic locality.

The carrier pays the QPA. The doctor sees 30-40% of what the same procedure would have paid pre-NSA. The gap is the structural failure.

Cause Two — Multi-CPT Downcoding

Carriers aggressively downcode complex procedure stacks. A patient who arrives with a complex facial laceration may have CPT 13132 (intermediate repair), 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 the second-largest contributor to the 30%-of-billed reimbursement reality.

Cause Three — Carrier Bet on Non-Disputation

Carriers know that most non-par ER providers will not file IDR. The administrative threshold (Open Negotiation Notice, FAIR Health benchmark pull, attorney-grade submission package, deadline tracking through to award) is real. Carriers price their initial offers to the level that maximizes total dollars retained net of expected IDR losses. If 80% of providers do not file, the carrier comes out ahead even when 100% of filers win.

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

The Recovery Path

State IDR moves the needle. New York §603-d, Texas IDR, Connecticut, New Jersey, Georgia, New Mexico — each has its own version. The state IDR systems anchor awards in FAIR Health UCR data, not carrier-internal QPAs. The state regulators enforce the awards under threat of insurer-license action. The collection rate on state IDR awards is effectively 100%.

Eliott Dear’s state IDR win rate across Claims Assassins filings is approximately 99%. Average award increase over the initial pay is in the 4-12x range, claim by claim. On a 10% contingency model, the math closes the 30-cents-on-the-dollar gap for the cases that are state-IDR eligible.

The problem is solvable. The lever is filing.