A TPA Case Study in NSA Performance

Better Outcomes Before IDR

A Minneapolis-based TPA partnered with Zelis to keep more claims out of independent dispute resolution (IDR)—and outperform benchmarks when arbitration was unavoidable.

Men and women discussing about the NSA case study about how TPA reduces IDR pressure

Executive Summary

A long-time Zelis client used defensible NSA pricing and strategic post-pay negotiation to manage rising independent dispute resolution (IDR) pressure in 2025. The program delivered significant upfront savings and outperformed benchmarks when IDR occurred.

Highlights (2025 performance)

  • 10,000+ NSA-eligible claims serviced ($31M billed charges)
  • 89% of priced claims avoided disputes (no negotiation or IDR initiated)
  • 58% of disputed claims resolved through open negotiation (avoided IDR)
  • 30% plan win rate in IDR — +18 pts vs. industry average
  • $25M in claim savings delivered + up to $578K in admin/IDRE fees avoideded

The Challenge

IDR Pressure is Rising

In early 2025, providers escalated more claims to IDR, and their win rates rose. As such, it’s more important than ever for plans and TPAs to (1) keep claims out of IDR when possible and (2) have a defensible approach when IDR is unavoidable.

This TPA’s goals were to:

  • Reduce provider friction and avoid dispute escalation
  • Maintain defensible pricing closer to QPA than market averages
  • Improve client experience by controlling cost and administrative burden

The Solution

Provider-accepted NSA Pricing + Strategic Negotiation Approach

The TPA partnered with Zelis on a two-part approach:

  • Provider-accepted NSA claim pricing
    The TPA used Zelis NSA pricing designed for provider acceptance to help reduce disputes and limit operational burden tied to negotiation and IDR.
  • Strategic negotiation
    When disputes did occur, the TPA worked with Zelis to run a structured open-negotiation strategy — resolving more cases before IDR initiation.

Results

Meaningful Savings Upfront + Stronger Outcomes When IDR Occurs

Across 10,000+ claims totaling $31M in billed charges, the TPA achieved results both upstream (pricing acceptance) and downstream (negotiation/IDR performance).

Upstream impact:

  • ~90% of NSA claims reimbursed without open negotiation or IDR following Zelis pricing recommendations
  • $25M+ savings delivered

Downstream impact:

  • 58% of provider-initiated disputes were resolved through strategic open negotiation, avoiding IDR escalation
  • ~$578,000 in CMS administrative and IDR entity fees were avoided
  • 4% of total NSA claim volume moved to IDR
  • 30% of IDR submissions were won in favor of the plan — 18 pts above the industry average

Why It Matters

Together, the TPA and Zelis helped deliver tangible value for employer group clients by:

  • Reducing arbitration exposure and limiting administrative overhead
  • Improving predictability and defensibility of out-of-network reimbursements
  • Maintaining momentum as IDR dynamics increasingly favor providers
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