The No Surprises Act and its arbitration system is now under more scrutiny than at any point since the law went into effect in 2022.
Providers have filed millions of disputes and are winning about 85% of them, but collecting on those wins has become an industrywide problem as nearly a third of awards go unpaid and federal courts have largely closed the door on providers suing to collect.
Meanwhile, one of the law’s original authors has proposed replacing arbitration altogether, insurers and employers are pushing for tighter controls on the process as costs climb, and provider groups, think tanks and researchers are each putting out new data to shape the reform debate heading into 2027.
Four No Surprises Act updates:
1. Regulatory
- CMS convened every certified IDR entity Oct. 1 to discuss rising costs and payment problems in the dispute process, alongside officials from HHS and the Labor and Treasury departments. CMS said it has received and closed more than 7 million disputes since April 2022, far exceeding expectations, and flagged ineligible disputes, unclear decision rationales and nonpayment of awards as top concerns.
- On Oct. 7, Rep. Frank Pallone Jr. (D-N.J.), one of the No Surprises Act’s original authors, introduced the Lower Premiums, Faster Payments Act, which would eliminate IDR arbitration for services provided on or after Jan. 1, 2028 and replace it with a payment standard based on the median in-network contracted rate, adjusted annually for inflation. The bill would also bar judicial review of the QPA methodology.
- In late October, the Coalition Against Surprise Medical Billing and the ERISA Industry Committee sent letters to federal officials calling for tougher oversight of IDR arbitrators during the recertification process. Both groups cited wide variation in arbiter outcomes, and CASMB requested a pause on recertifications until higher standards are established.
- Federal regulators released guidance Oct. 29 on how IDR disputes can be batched and bundled under a final rule finalized in May. The new batching rules, which took effect Nov. 1, cap batched disputes at 50 line items and tighten the criteria for grouping claims into a single determination.
- On Nov. 4, HHS, the Labor Department and the Treasury Department denied recertification to two IDR entities (Island Peer Review Organization and Network Medical Review Company), citing failure to meet minimum performance standards.
2. Litigation
- On Sept. 17, a New York state court dismissed a lawsuit from two Long Island medical practices that sought more than $1.7 million from Elevance Health subsidiaries over unpaid IDR awards. The court ruled that every claim depended on the federal IDR determinations for both the obligation to pay and the dollar amount owed, and that state-law claims cannot fill the gap when no private right of action exists under the No Surprises Act.
- The Second Circuit ruled Sept. 17 that a plastic surgery practice cannot sue Cigna to collect more than $3 million in unpaid IDR awards, holding that the NSA doesn’t give providers a private right of action to enforce them.
- In October, Intraoperative neuromonitoring provider SpecialtyCare and two affiliated physician groups sued Anthem Virginia over roughly $2.5 million and separately, Anthem Colorado, over $501,000 in unpaid IDR awards, alleging the insurers missed the 30-day federal payment deadline on every disputed amount.
3. Insurers’ perspective
- UnitedHealthcare CEO Tim Noel said during an Oct. 13 earnings call that arbitration awards are reaching nearly 6% of total commercial medical spend in some regions. Separately, Cigna Group CFO Ann Dennison said at the UBS Global Healthcare Conference Nov. 10 that IDR added about 60 basis points of cost trend pressure in 2026 and is expected to add more next year.
4. Research and analysis
- Anthem hasn’t paid 74% of the arbitration awards it’s lost since 2024, the highest nonpayment rate among major insurers, The New York Times reported Nov. 3. Across all insurers, 29% of awards went unpaid, according to HaloMD data on more than 409,000 cases that was reviewed by the Times. As of 2026, Anthem’s nonpayment rate was 83%, and the Labor Department said it is investigating.
- The Paragon Health Institute, a conservative health policy think tank, published an analysis Aug. 27 of IDR public use data finding that the median arbitration award in 2025 was nearly four times the QPA and 5.5 times the Medicare rate, with 90th-percentile awards reaching nearly 18 times the QPA. The institute recommended a two-track framework that would eliminate the IDR process for elective services and either eliminate or significantly restrict it for emergency care, including capping awards and updating the QPA to reflect current in-network rates rather than inflation-adjusted 2019 rates.
- Researchers at the USC Schaeffer Institute argued Nov. 6 that Congress should preserve the NSA’s consumer protections while making targeted fixes to arbitration rather than scrapping it, as the Pallone bill and the Paragon proposal would each do in different ways. The piece recommended letting arbitrators pick any value within the range of the two offers instead of the current baseball-style format, scaling arbitration fees to the value of disputes, and strengthening eligibility screening so arbitrators have no financial incentive to let ineligible claims proceed.
- The Emergency Department Practice Management Association, which represents emergency medicine staffing and management groups, released a two-part analysis Nov. 9 of actual payment data from members who collectively serve roughly 60% of emergency department visits nationally. The first report found that initial out-of-network payments for a common ER visit code fell 49.7% after the No Surprises Act, and that IDR awards averaged 98% of the inflation-adjusted pre-NSA rate. The second found that average commercial cash per visit fell 6% after the law, and even assuming every IDR award was paid, total payments remained below pre-NSA levels after adjusting for inflation. Respondents reported $78.3 million in unpaid awards as of August.
- Georgetown University researchers analyzed three years of federal IDR data in a Nov. 11 report and found that insurers offered amounts at or above the QPA in roughly 90% of disputes, while default determinations went in providers’ favor 91% of the time in 2025, up from 59% in 2023. Providers’ overall win rates also held steady even after excluding defaults. The researchers noted that insurer win rates didn’t improve even when they raised their offers.
