One might be forgiven for believing the great debate has already been settled. The discourse has been most animated, after all, on matters of volume and velocity. How many cases. How long they linger. Whether the machinery of adjudication can keep pace with the ambition of its design.

These are tidy questions. Respectable questions. But they are not the most interesting ones.

Because beneath the ledgers and timelines, a quieter narrative has begun to circulate. Not in formal reports, but in the corridors between them. In the follow ups. In the polite inquiries that arrive weeks after a decision has already been rendered.

Providers are winning, and still not getting paid. The payers are singing another anthem, united in writing another path forward.

Industry estimates now point to hundreds of millions of dollars in awarded claims that remain outstanding. Not under appeal. Not overturned. Simply… unfulfilled. Suspended somewhere between determination and delivery, as though the final act of the process were optional rather than implied.

Which invites a rather delicate question: If a system produces winners, but does not reliably produce payment, what precisely has been resolved?

The Independent Dispute Resolution process was introduced with admirable clarity of purpose. A structured forum. A neutral arbiter. A binding decision. A protected patient experience. A means, at last, of replacing protracted negotiation with something more orderly, more predictable, more fair.

And after three years of adjustments, these opening movements perform quite well. Cases are submitted. Evidence is considered. Awards are issued. Value is, in fact, determined.

But it is in the final movement, the one that follows the applause, where the composition begins to lose its discipline.

For once a determination is made, the system steps back. The burden of execution returns to the very parties whose incentives necessitated arbitration in the first place. And it is here, in this quiet transfer of responsibility, self-enriching behavior reasserts itself.

Payment timelines lengthen. Follow ups accumulate. What was meant to be a resolution begins, almost imperceptibly at first, to resemble a continuation, only now with more paperwork and less certainty.

And then, inevitably, one notices the asymmetry.

Providers operate within a regime of well-defined obligation. Even modest missteps can carry consequences, often in the range of ten thousand dollars per patient when enforced. The expectation is clear. Accuracy is not merely encouraged. It is required, and deviations are not without cost.

Payers, by contrast, are afforded a more flexible posture once an IDR determination is made. There is no equivalent, time bound enforcement mechanism that compels payment within a defined window. No automatic penalty that attaches to delay. No structural consequence that mirrors the discipline applied elsewhere in the system.

One side operates under defined penalties. The other, under optionality. And optionality, as it so often does, becomes strategic.

For even after an award has been issued, the matter does not always conclude. Claims may be reprocessed. Patient responsibility recalculated. Adjustments introduced that, while technically compliant, have the practical effect of reshaping the financial outcome.

The decision, one observes, remains intact. The economics, however, are subject to revision.

There is no need to assume ill intent to understand this pattern. It is sufficient to recognize the incentives at play. In a system where delay carries no immediate consequence, delay becomes a rational choice. Cash is retained. Timelines stretch. And a certain percentage of claims, through fatigue or pragmatism, are simply not pursued to their logical end.

Even the capital meant to support resolution does not always move with the urgency of the decision itself. Administrative fees and arbitration costs, held in what functions as escrow, are not consistently returned on timelines that reflect a system designed for clarifying finality.

In private conversations, concerns are beginning to surface about the handling of these funds at scale, with some suggesting that material sums may be sitting in limbo longer than intended. Whether operational backlog or something more structural, the effect is the same. Capital that should reinforce trust in the process instead introduces a second layer of uncertainty.

At a certain scale, delay begins to resemble something more than timing. And so the process completes, at least in theory. The outcome is known. The record reflects a resolution. Yet justice is not concluded.

Over time, such patterns have a way of shaping behavior. Smaller providers, already constrained, begin to question the value of engagement. Larger organizations grow selective in their pursuits. The theoretical promise of IDR begins to diverge, ever so slightly at first, from the cash that ultimately arrives.

And in that divergence, one finds the beginnings of a more structural concern.

For a system that determines value but does not ensure its delivery is not, in the strictest sense, resolving disputes. It is extending them under more formal terms, as an abandonment of the rule of law.

Even as policymakers, including physician legislators such as Greg Murphy, have devoted considerable effort to refining how IDR decisions are rendered, far less attention has been given to what becomes of those decisions once they are made.

It is perhaps in that omission that the system reveals its most telling characteristic. Adjudication has been defined with precision. Enforcement, rather less so. The rules describe how decisions are reached, but remain curiously understated on how those decisions are to be carried through.

In the absence of such structure, the market does what markets invariably do. It optimizes. Not for fairness. For advantage.

Which leaves regulators and policymakers with a question that is at once simple and rather consequential.

Is the purpose of this system to render decisions, or to ensure that those decisions carry respect? Because at present, the distinction is not merely academic. It is operational. And increasingly, it is financial.

The remedies themselves are not especially mysterious. Payment following an award could be automatic, governed by clear and enforceable timelines. Delays could carry consequences proportionate to their impact. Escrow processes could be bound by defined service expectations. Transparency could extend beyond the outcome of disputes to include adherence to those outcomes.

Such measures would not alter the spirit of the system. They would complete it. Until then, we remain in a rather peculiar arrangement. Where disputes are resolved on paper. But not always in practice.

And where victory, for many, is less a conclusion than an invitation to begin again yet another administrative task. One suspects the market will not remain so patient indefinitely.

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‍Larrian Martin is the Chief Information Officer at GoSB, a specialty RCM company, and formerly EVP of Data & Insights at Envision Healthcare.

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