Madison Law Firm PLLC represents out-of-network surgeons, anesthesiologists, and specialists in New York surprise billing arbitration and federal No Surprises Act IDR proceedings — recovering the full reimbursement the law entitles you to.
Contingency representation — no fee unless we recover. Free accounts receivable review included.
Every year, out-of-network surgeons, anesthesiologists, radiologists, and other specialists across New York City accept insurance payments that are a fraction of what the law actually entitles them to. The insurance carriers know this. They have actuarial models built around provider inaction.
Under the federal No Surprises Act and New York's own Surprise Bill Law, you have a legally enforceable right to demand more — through a binding arbitration process administered either by the New York Department of Financial Services or by the federal Centers for Medicare & Medicaid Services. The arbitrator picks either your number or the insurer's. Providers win the majority of these cases.
The practical barrier is not the law. It is knowing the process exists, meeting the deadlines, and preparing the evidentiary submission that gives the arbitrator a compelling basis to choose your number over theirs. That is precisely what we do.
"On a $50,000 charge, we have seen insurance carriers pay less than $1,000. The law gives providers the right to challenge that. Most simply don't."
Depending on the type of insurance your patient carries, either New York State law or the federal No Surprises Act will govern your dispute — or both. Understanding which applies is the first step to maximizing your recovery.
New York was among the first states to pass comprehensive surprise billing protection, initially in 2015 and substantially expanded in 2018. The operative statute is the Out-of-Network Consumer Protection, Transparency, Cost Containment, and Accountability Act, NY Insurance Law §§ 3217-d and 3241. It applies to fully insured commercial health plans regulated by New York State — Aetna, United, Cigna, Oxford, Emblem, Blue Cross Blue Shield, and others.
The NY Benchmark Advantage: NY arbitrators consider the 80th percentile of FAIR Health billed charges — the amount higher than what 80% of physicians charge nationally for the same CPT code in the same region. This is dramatically more favorable than Medicare rates or the federal QPA standard.
The No Surprises Act was enacted as part of the Consolidated Appropriations Act, 2021 (Pub. L. 116-260), effective January 1, 2022. It is codified at 42 U.S.C. §§ 300gg-111, 300gg-112 and implemented by 45 C.F.R. Part 149. The federal IDR process applies primarily to self-funded ERISA plans — large employers who self-insure rather than purchase fully insured coverage — which the NY state law cannot reach.
The Federal Benchmark: The Qualifying Payment Amount (QPA) — the insurer's median contracted rate — is the primary benchmark. Unlike NY law, arbitrators cannot consider billed charges. However, a federal court struck down the rule requiring arbitrators to presume the QPA is correct, freeing them to weigh all factors equally. Providers win approximately 85% of federal IDR disputes.
| Factor | NY State IDR (DFS) | Federal NSA IDR (CMS) |
|---|---|---|
| Applies to | Fully insured NY commercial plans (individual, small & large group, HMO/EPO) | Self-funded ERISA plans; federal employee plans; grandfathered plans post-1/1/22 |
| Filing deadline | 3 years from date of service — prior claims recoverable | 4 business days after 30-day open negotiation fails |
| Arbitration benchmark | 80th percentile FAIR Health billed charges — highly provider-favorable | QPA (insurer's median contracted rate) — one of several factors considered |
| Arbitration style | IDRE selects provider's bill OR insurer's payment | Baseball-style: IDR entity selects one party's offer; no compromise |
| Decision timeline | 30 days from IDRE receipt | 30 business days after IDR entity selection |
| Who administers | NY Department of Financial Services | Centers for Medicare & Medicaid Services (CMS) |
| Post-award enforcement | Court enforcement available if insurer refuses to pay | CMS oversight; court enforcement; only 52% of awards paid timely in 2023 |
Every specialty below routinely generates out-of-network encounters in New York — either because the provider is not in the patient's network, or because the patient is referred to them without meaningful choice. Each creates valid IDR claims.
The single most frequent user of NY state IDR arbitration. Emergency room plastic surgeons operating at in-network hospitals generate surprise bills with every procedure. Covered under both state and federal law depending on patient's plan.
Patients select their in-network surgeon — not their anesthesiologist. When the anesthesiologist is out-of-network at an in-network facility, the patient receives a surprise bill. One of the highest-volume IDR specialties nationally.
Patients are almost never aware of the assistant surgeon's network status. Under the NY Surprise Bill Law, assistant surgeon charges posted the largest percentage increase in billed charges following the law's passage — a 24%+ average increase.
Emergency services are protected under both NY and federal law regardless of facility network status. EM physicians operating out-of-network at in-network facilities cannot balance-bill patients — but can and should pursue IDR for full reimbursement.
High-CPT-code surgical procedures create significant arbitration opportunity. Covered under the federal NSA for non-emergency procedures performed at in-network ASCs and hospitals — including elective cardiac and thoracic surgeries.
Complex spinal and neurological procedures generate some of the highest-value claims in this practice area. Surgeons who operate at in-network facilities where their own network participation differs from the facility's create classic IDR scenarios.
Laboratory and diagnostic services are explicitly named in the surprise billing statutes. High-volume practices benefit from claim batching under the federal IDR process — submitting multiple same-payer, same-CPT claims in a single proceeding.
Called in to treat patients at in-network facilities without advance patient selection. All three specialties are expressly designated as covered providers under both NY state law and the federal No Surprises Act, effective January 1, 2022.
We manage the entire IDR process from claims identification through award enforcement. Your responsibility is to provide patient records and billing documentation. Ours is everything else.
We audit your accounts receivable at no charge, identifying underpaid claims eligible for NY state IDR or federal NSA arbitration. We assess potential recovery and outline a strategy specific to your specialty and payer mix.
We pull FAIR Health benchmark data for your CPT codes, document your credentials and usual charges, gather EOBs and correspondence, and build the evidentiary submission the arbitrator will receive. Strong preparation is the single largest driver of outcomes.
We file via the DFS portal (NY state claims) or the CMS federal IDR portal. We conduct open negotiations with the payer and, if those fail, prosecute the arbitration through hearing. We handle all deadlines, correspondence, and IDRE communications.
When we prevail, the insurer must pay within 30 days. If they delay or refuse — a documented pattern — we engage CMS (for federal claims) and pursue court enforcement where necessary. We do not consider the matter closed until you receive payment.
New York's Surprise Bill Law contains a provision that most out-of-network providers — and many attorneys — are unaware of: the filing window is three years from the date of service. Not 30 days. Not 90 days. Three years.
This means that claims your billing department marked as uncollectable in 2022 or 2023, claims that were denied, underpaid, or simply never disputed — may still be eligible for arbitration today. A single surgical practice with $400,000 in underpaid commercial insurance claims from the past three years could potentially recover a significant portion of that backlog through the NY DFS IDR process.
The insurance carriers are aware of this window. They are counting on the vast majority of providers not using it. We help you use it.
NY arbitrators consider the 80th percentile of FAIR Health billed charges — the dollar amount above what 80% of physicians nationally charge for the same CPT code. This benchmark is dramatically higher than Medicare rates and the federal QPA, and is the core reason NY state IDR outcomes are superior to federal IDR for many specialties.
NY IDREs also consider the provider's training, education, experience, and usual and customary charges; fees paid for the same services to other out-of-network providers in the same region; and the provider's pattern of charges to other payers. Building the record on all of these factors — not just the FAIR Health data — is central to our approach.
Unlike pure arbitration filing services, Madison Law Firm is a licensed New York law firm prepared to enforce IDR awards in court if an insurer refuses to pay. We also handle ERISA litigation and federal court proceedings when the facts warrant — giving insurers a reason to settle before arbitration rather than after.
We handle surprise billing arbitration on a pure contingency basis. We do not charge a retainer, filing fees, or hourly rates for this practice area. We are compensated as a percentage of the recovery above your initial insurer payment. If we do not recover, you owe nothing. The financial risk is ours, not yours.
Tell us about your practice, your specialty, and your approximate volume of out-of-network commercial insurance claims. We will conduct a no-obligation review of your accounts receivable to identify eligible claims under both New York state law and the federal No Surprises Act, and provide a candid assessment of the recovery potential.
There is no cost to this review. There is no obligation to engage us. And if we do take your matter, there is no fee unless we recover.
Complete the form below. A member of our healthcare arbitration team will respond within one business day.