Top 5 Reasons Your Medical Revenue Claims Are Underpaid - And How to Win Them Back

The top 5 reasons your medical revenue claims are underpaid are:

QPA reductions and out-of-network payment limits.
Downcoding and acuity disputes.
Medical necessity denials.
Post-stabilization coverage disputes.
Improper bundling of procedures.

Insurance companies often pay only 3% to 10% of what out-of-network emergency surgeons bill. They say they only have to pay the average in-network rate. Or, that the patient was already stable, so the rest of the treatment wasn’t an emergency.

Over time, repeated underpayments on complex surgeries can result in significant lost revenue. This is the reality for many out-of-network and emergency surgeons.

But you don’t have to accept these underpayments. The No Surprises Act created a process called Independent Dispute Resolution (IDR) to resolve eligible out-of-network payment disputes. It’s important to understand why claims are underpaid so you can use IDR the right way.

Callagy Recovery helps you fight low insurance payments. We can recover 5x to 15x the initial amount.

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Why Are Your Medical Revenue Claims Underpaid?

Reason 1: Insurance Companies Use QPA for Out-of-Network Payments

Insurance companies use the Qualifying Payment Amount (QPA) for out-of-network payments to lower reimbursement. The QPA is supposed to be the median in-network rate for your procedure in your area. However, when calculating the QPA, insurers often:

Base it on median contracted rates for the same service.
Include contracted rates across different providers and settings.
Rely on a mix of different agreements and reimbursement levels in the data.

The QPA becomes the baseline payment reference, even when it doesn’t reflect the complexity of the surgery. For example, a neurosurgeon might bill $120,000 for a complex emergency craniotomy. The insurer may:

Set the QPA at $3,600.
Pay that allowed amount.
Justify it as the “median in-network rate”.

Reason 2: Insurance Companies Downcode Emergency Medical Services

Insurance companies downcode emergency medical services by disputing patient acuity and complexity. For example, you bill a Level 5 emergency department visit. You’re called for a severe facial trauma case. The patient has extensive soft tissue injuries, possible airway involvement, and requires complex reconstruction planning. The case is highly complex and time-sensitive. However, the insurer downcodes it to a Level 3 and pays less. The insurers’ arguments go something like this:

“The patient wasn’t sick enough to justify Level 5.”
“The notes don’t show enough detail about how serious or risky the case was.”
“The notes don’t clearly show how complex the decision-making and treatment were.”

This is often coded as: CO-11 = incorrect coding.

Reason 3: Insurers Review Medical Necessity After the Service

Insurers review medical necessity after the service and may reduce or deny payment based on their own criteria. Emergency surgeons work under EMTALA (Emergency Medical Treatment and Labor Act). It requires screening and stabilization of emergency patients, no matter what. So:

You can’t turn someone away because of their insurance.
You can’t delay care to check coverage.
You treat based on the patient’s condition right away.

But later, insurance companies review the case. They look back and decide if they think the treatment was “necessary.” If not, they may reduce payment or deny the claim altogether. They might say:

“The case wasn’t serious enough for emergency surgery.”
“The diagnosis or coding was wrong.”
“The patient could have been treated in a non-emergency setting.”

This is coded as: CO-50 = services not deemed medically necessary.

Reason 4: Insurance Companies Deny or Limit Post-Stabilization Care

Insurance companies deny or limit post-stabilization care by applying transfer and authorization requirements. In many cases, a trauma patient is stabilized in the ER but still needs urgent surgery. You proceed because transferring the patient may not be safe. Later, the insurer denies the claim and says:

“The patient should have been transferred to an in-network hospital.”
“The care after stabilization is no longer considered emergency-level care.”
“Prior authorization or precertification was required.”

These denials are often processed using codes like: CO-15 = missing authorization and CO-197 = precertification required.

Reason 5: Insurance Companies Bundle Distinct Procedural Services

Insurance companies bundle distinct procedural services by denying separate payment for additional procedures. Sometimes you perform 2 separate procedures during the same surgery. For example, you may fix a broken femur (ORIF) and also clean an open knee wound (irrigation and debridement) during the same surgery. These are distinct procedures involving different anatomical areas and purposes. The insurer denies the second procedure and bundles it into the first. This means it’s not separately payable.

This is often coded as: CO-97 = service already included / previously adjudicated.

How Can You Fight Underpaid Medical Revenue Claims?

You can fight underpaid medical revenue claims through the Independent Dispute Resolution (IDR) process. Here’s how it works:

The insurer underpays or denies your claim.
You have 30 days to negotiate higher pay directly with the insurer.
If no agreement is reached, you can start the IDR process.
Both sides submit a final payment offer to a certified arbitrator.
You must include supporting documentation (clinical notes, billing details, justification).
The arbitrator reviews both offers and supporting documents.
The arbitrator must choose one offer only (no splitting the difference).
The decision is final and binding.

What Is the Independent Dispute Resolution (IDR)?

The Independent Dispute Resolution (IDR) is a federal process under the No Surprises Act used to settle payment disputes between out-of-network providers and insurers. It applies when:

The service is covered (the insurer accepts it as a valid, billable medical service).
The dispute is only about how much should be paid.

IDR works best when your documentation, coding, and market data clearly support the reimbursement you are requesting. The arbitrator’s decision is awarded to the side that’s better supported by the evidence and aligns with reasonable reimbursement standards. So if you present strong and relevant data, you are more likely to win these disputes and recover the money you rightfully earned.

How Do You Win the IDR Process for Different Types of Medical Revenue Claims?

QPA / low out-of-network payment.

✅ This is the most direct and strongest IDR category.

👉 Win point: You are proving the insurer’s QPA-based payment is below fair market value for your region and case type.

🏆 How to win:

Show local market payment data for similar services.
Compare in-network vs out-of-network reimbursement in your area.
Prove the QPA does not reflect complex emergency or surgical cases.
Demonstrate higher payments for similar procedures in regional benchmarks.
Support your billed amount with case complexity and resource intensity.

Downcoding (CO-11).

✅ IDR eligible if dispute is about payment level for a covered service.

❌ Not eligible if insurer claims coding is incorrect or unsupported.

👉 Win point: You win by proving the record supports the higher level of service billed.

🏆 How to win:

Show documentation that supports higher acuity level (e.g., Level 5 vs Level 3).
Highlight vital signs, instability, and presenting severity.
Demonstrate strong medical decision-making complexity.
Match documentation to CPT criteria for the billed level.
Prove insurers ignored documented clinical severity.

Medical Necessity (CO-50).

✅ IDR eligible if service is covered but payment is reduced after review.

❌ Not eligible if insurer determines the service is not covered under the plan.

👉 Win point: You win by proving the decision was appropriate at the time of treatment.

🏆 How to win:

Show patient condition at time of presentation.
Document symptoms, risk factors, and clinical urgency.
Reinforce real-time emergency decision-making.
Support that care followed accepted emergency standards.
Prove that the insurer is applying hindsight review instead of clinical context.

Post-Stabilization Denials (CO-15 / CO-197).

✅ IDR eligible if patient could not be safely transferred.

❌ Not eligible if insurer proves transfer was medically safe.

👉 Win point: You win by proving the transfer was unsafe at the time of treatment continuation.

🏆 How to win:

Show ongoing instability after initial stabilization.
Document risk factors preventing safe transfer.
Explain clinical reasons for continued treatment.
Highlight emergency conditions (hemodynamic, respiratory, neurologic).
Prove transfer would have created unacceptable clinical risk.

Bundling (CO-97).

✅ IDR eligible if dispute is about separate payment for distinct services.

❌ Not eligible if insurer treats it as a coding/NCCI edit issue only.

👉 Win point: You win by proving the procedures are separate and independently billable.

🏆 How to win:

Show procedures are clinically distinct and separately necessary.
Document different anatomical sites or surgical purposes.
Clearly describe both procedures in operative notes.
Use correct CPT modifiers when applicable.
Align documentation with NCCI rules for separate reporting.

Why Many Out-of-Network Surgeons Don’t Use IDR Correctly?

They don’t know about it. An estimated 9 out of 10 surgeons don’t know they can challenge insurer underpayments. So they don’t use IDR at all.
They don’t know which claims qualify. Surgeons submit all types of denials for IDR, which leads to rejection or dismissal. Other surgeons avoid filing because they’re unsure whether the dispute meets IDR rules and want to avoid wasting time.
They don’t have supporting data ready. Surgeons don’t know about market comparisons, Medicare or regional benchmarks, and structured documentation. They submit their payment amount without evidence.
They miss strict deadlines. Surgeons fail to complete the 30-day negotiation period or miss the deadline to initiate IDR. They also submit the required documents late. This results in case dismissal or forfeiture.
They misunderstand how arbitration works. Surgeons submit unrealistic payment demands without support. The insurer’s offer appears more reasonable by comparison. The arbitrator selects the better-supported offer. They can’t pick a number in between.
They don’t follow through after filing. Surgeons assume the insurer will automatically pay after they win the IDR decision. But insurers sometimes delay or fail to issue payment, and surgeons take no escalation or enforcement action when needed.

Why Hire a Medical Revenue Recovery Specialist for IDR?

They identify specific underpayments that get missed in daily billing. This includes reduced payments from QPA calculations, downcoded visit levels (such as Level 5 paid as Level 3), and bundled procedures.
They understand how insurers actually reduce payment on claims. They know how CO-11, CO-50, CO-15, CO-197, and CO-97 are applied to lower reimbursement.
They filter which disputes are actually worth pursuing. They focus on eligible, high-value claims and avoid wasting time on denials that don’t qualify for IDR.
They build IDR-ready and appeal-ready cases. They organize operative notes, CPT justification, and payer comparison. Your dispute is supported by clear clinical and financial evidence.
They manage deadlines that control payment recovery. They ensure eligible claims are not lost due to timing or process errors. This includes the 30-day open negotiation period, the IDR filing window, and required documentation timelines.
They handle insurer pushback after denials or appeals. They respond when insurers reject arguments, dispute eligibility, or delay resolution, so cases don’t stall or get dismissed.
They track claims through resolution, not submission. They follow up after decisions to make sure insurers pay the correct amount on time and don’t short-pay or delay payment.
They recover revenue that is usually written off internally. Many claims are considered “final paid” by billing teams. These claims can still be challenged and increased through proper review and escalation.
They prevent repeat underpayments from happening. They identify the patterns in insurer behavior so the same types of claims are not continuously reduced or downcoded.
They allow you to focus on patient care. This helps you spend more time saving lives while ensuring you receive the payment you rightfully earned for your work.

Why Choose Callagy Recovery to Dispute Your Underpaid Medical Revenue Claims?

We specialize in federal and state arbitration. We know the rules, required documents, and deadlines for both processes.
We handle the full dispute process. This includes negotiation, arbitration, and post-decision recovery.
We have 27+ years of experience. We know the common insurer arguments and how to effectively challenge them.
We pay all the upfront costs. There’s zero risk for you.
We only ask for 20% of the recovered amount. You only have to pay if we win the case for you.
We win 94% of our cases. We have a strong track record in IDR disputes.
We file 4,000 cases each month. We are trusted by out-of-network surgeons all over the country.
We are 100% transparent. You can use our portal to track your claims at every stage of the process.
We have already recovered over $1 billion. In December 2025 alone, we recovered $100 million. Our highest single recovery was $83,120 for a neurosurgeon.

Are You Ready to Recover Your Underpaid Medical Claims?

Underpayments in out-of-network and emergency surgery are not random. They follow clear patterns like QPA reductions, downcoding, medical necessity reviews, post-stabilization disputes, and bundling issues.

These reductions don’t reflect the true value of your work. They reflect how insurers review and reduce payment after the treatment has already been provided and billed. Many of these claims can still be challenged and recovered when the proper process is used within the required timelines and supported with the right documentation.

This is exactly where Callagy Recovery steps in. We handle the burden of fighting insurers, building arbitration-ready cases, and pursuing full payment recovery from start to finish.

SCHEDULE YOUR FREE CALL WITH CALLAGY RECOVERY HERE!