The No Surprises Act’s independent dispute resolution process has generated an estimated $22.4 billion in total costs over its first four years, according to an analysis published Aug. 26 in Health Affairs Forefront.
The researchers from Georgetown University’s Center on Health Insurance Reforms examined federal public use file data on IDR outcomes from 2022 through 2025.
Seven things to know:
1. The $22.4 billion estimate covers three categories of costs attributable to IDR from 2022 to 2025. The largest component, $15.6 billion, represents payment awards by IDR entities that exceeded in-network rates as measured by the qualifying payment amount. Internal administrative costs for plans and providers accounted for $4.2 billion, and administrative and IDR entity fees made up the remaining $2.7 billion.
2. The researchers designed the estimate to capture costs that would not exist if providers accepted initial plan payments rather than pursuing arbitration. They measured the gap between what IDR entities awarded and the QPA, which is defined as the median contracted in-network rate. They calculated internal administrative costs using the federal agencies’ own estimate of $857 per dispute, multiplied by total disputes initiated. The authors noted their estimate is conservative, as it does not account for costs tied to third-party middlemen, IDR-related litigation or fees that insurers and third-party administrators may charge employers to manage the process.
3. Dispute volume rose 77% from 2024 to 2025, with providers initiating 2.6 million new disputes last year. Federal agencies had originally projected approximately 22,000 disputes per year. In the first six months of 2026, 1.75 million disputes were filed, or 50% higher than the same period in 2025.
4. Three organizations accounted for more than three-fourths of resolved dispute lines in 2025: Radiology Partners (30%), HaloMD (27%) and TeamHealth (20%). Emergency medicine and radiology represented 41% and 29% of all dispute lines from 2023 to 2025, respectively.
5. Providers prevailed in roughly 85% of all disputes in 2025, with four of the five largest filers having win rates above 90%. The analysis found significant variation among IDR entities, with one entity ruling for providers in 99.4% of disputes and awarding a median of 601% of QPA, while another ruled for providers in 54.5% of cases with a median award of 159% of QPA. The researchers noted that IDR entities with the highest provider win rates handled the largest case volumes, consistent with provider-side selection of favorable arbitrators.
6. Total payment awards rose 264% from 2024 to 2025, far outpacing the 77% growth in dispute volume. The median prevailing provider award in 2025 was 445% of QPA. At the 90th percentile, awards reached 1,771% of QPA, up from 1,226% in 2024. Certain specialties also saw especially large awards relative to their dispute share. Surgery accounted for 5% of disputes but $3.8 billion in total awards from 2023 to 2025, while neurology and neuromuscular services, also 5% of disputes, totaled $2.02 billion.
7. Self-insured employers and insurers have begun reporting the effects on premiums. For example, New York’s Department of Civil Service reported more than $200 million in additional claim payments from IDR for its state employee health plan, which the agency called a primary contributor to a nearly 10% premium rate increase in 2025. The researchers wrote that without legislative changes, escalating IDR costs will likely contribute to even higher premiums in the future, along with increased patient cost sharing, narrower provider networks and restricted wage growth.
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