The No Surprises Act’s independent dispute resolution process has now generated more than $22 billion in total costs since 2022, with dispute volume still accelerating and the courts, Congress and federal regulators all moving in different directions on how to respond. Providers continue to win about 85% of resolved cases, insurers are calling for major reforms to the process, and federal judges have now rebuffed multiple insurer lawsuits alleging providers are gaming the system.
Five No Surprises Act updates:
1. Legislative
- In September, Rep. Frank Pallone Jr. (D-N.J.) sent oversight letters to six IDR arbitration firms seeking documents on dispute volumes, eligibility screening, use of AI and financial ties between the firms and the parties whose disputes they handle.
2. Litigation
- In September, air ambulance operator PHI Health sued Anthem BCBS, alleging the insurer has refused to pay more than 1,200 binding IDR determinations totaling roughly $30 million nationally.
- In August, the Fifth Circuit ruled that the government’s methodology for calculating the qualifying payment amount is partly unlawful, finding that agencies improperly allowed insurers to include “ghost rates” and exclude bonus payments in QPA calculations. The court sided with the government on air ambulance billing, finding that one-off emergency agreements are not “contracted rates” under federal law.
3. Research
- In July, a Wall Street Journal analysis of federal data found that the IDR process awarded close to $15 billion to providers in 2025, up from $4.08 billion in 2024. Providers prevailed in about 85% of determinations in the second-half of last year.
- In August, researchers from Georgetown University published an analysis in Health Affairs that found the IDR process has generated an estimated $22.4 billion in total costs over its first four years. Dispute volume rose 77% from 2024 to 2025, with providers initiating 2.6 million new disputes last year and prevailing in roughly 85% of cases. Three organizations accounted for more than three-fourths of resolved dispute lines in 2025: Radiology Partners (30%), HaloMD (27%) and TeamHealth (20%).
4. Providers’ perspective
- Physician groups have pushed back on the Georgetown study’s $22.4 billion estimate, with ACEP, ACR and ASA arguing the analysis treats insurers’ QPA as an accurate benchmark when courts and arbitrators have repeatedly found otherwise. The associations estimated at least $6 billion of the study’s figures may reflect data errors or double-counted costs, and said scrutiny of the IDR process should also extend to inaccurate QPAs, lowball insurer offers and delayed payment of arbitration awards.
5. Insurers’ perspective
- Throughout the summer, leadership at UnitedHealthcare, Cigna, Elevance Health and Aetna escalated their public criticism of the IDR process, framing it as being exploited by a concentrated group of providers at the expense of employers.
- Multiple cost trend analyses released this summer identified the IDR process as a factor driving health insurance costs higher in 2027. PwC, which projects a 9% medical cost trend for the commercial group market next year, listed the high insurer loss rate under IDR arbitration among five key inflators, while ACA and small group insurers also cited the dispute process as a cost driver in their rate filings.
- In July, the Coalition Against Surprise Medical Billing, which includes AHIP and employer groups, launched a six-figure ad campaign against the bipartisan No Surprises Act Enforcement Act, which would impose stronger penalties on parties that miss payment deadlines after IDR determinations. Separately, 58 employers and employer groups sent a letter to House Ways and Means leaders opposing the bill, arguing it would worsen the affordability crisis rather than fix what they called a broken IDR system.
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