The No Surprises Act’s independent dispute resolution process continues to be a source of controversy and litigation nationally more than three years after its implementation, with insurers and providers suing over alleged abuse of the arbitration system.
The disputes come as research shows the IDR process has generated at least $5 billion in costs since 2022, prompting lawmakers to call for stronger federal enforcement and insurers to implement controversial reimbursement policies.
Eleven updates:
Policy
1. Fourteen House lawmakers called for a federal investigation of Elevance Health’s new policy that penalizes hospitals 10% for using out-of-network providers, arguing it is anti-competitive and circumvents the IDR process. The lawmakers and hospital groups say the policy pressures hospitals to force unsustainable rates on physicians, while Elevance defended it as addressing IDR abuse, citing a 40% increase in case volume in 2025 and examples like elective procedures generating arbitration payments far exceeding Medicare rates.
2. Blue Cross of Idaho requested a state insurance department investigation of Nutex Health in November after failed negotiations with the organization, citing a hospital’s practice of submitting 60% to 70% of billable visits to NSA arbitration monthly with payments often exceeding 1,000% of Medicare rates.
3. Republican lawmakers pressed the Trump administration in September to strengthen NSA enforcement, citing delayed implementation of the IDR Operations Rule (proposed in October 2023) and ongoing problems with QPA calculations, claim eligibility, payment delays, and lack of advanced EOBs.
Research
4. Providers win about 80% of NSA arbitration cases, with median payments reaching 3.72 times the qualifying payment amount, 2.04 times actual median local in-network rates, and 4.5 times Medicare rates, according to Elevance Health Public Policy Institute research published in December.
5. AHIP and BCBSA published a survey in October finding that health plans identified 39% of provider disputes in 2024 as ineligible for the NSA’s IDR process, while arbiters have determined only 17% are ineligible.
6. A BMJ study published in August found the NSA is tied to an 18% decline in out-of-pocket spending among adults with direct purchase private insurance, saving families an average of $567 annually in states that gained NSA protections compared to states with pre-existing comprehensive protections. The analysis of more than 17,000 adults from 2019 to 2024 found family out-of-pocket spending fell from $3,674 to $2,922 in newly protected states, while the NSA did not significantly affect premium spending or high-burden medical spending.
7. The IDR process has generated at least $5 billion in costs since launching in 2022, with administrative expenses accounting for more than half at $2.8 billion, according to a Health Affairs study published in August. Federal regulators originally projected 17,000 annual disputes, but more than 3.3 million were filed from mid-2022 to May 2025, with providers winning 85% of disputes in 2024 at median payment determinations of 459% of QPA (up from 327% in 2023), requiring insurers to pay $2.24 billion above in-network rates in 2023 and 2024.
Lawsuits
8. Anthem Blue Cross filed a lawsuit in January accusing 11 Prime Healthcare hospitals in California of extracting more than $15 million in improper payments by flooding the IDR process with over 6,000 ineligible claims since January 2024.
9. BCBS Texas filed a lawsuit in December against medical billing company Zotec Partners, alleging the company knowingly initiated thousands of ineligible disputes through the IDR process by submitting false information, ignoring state law and eligibility parameters, and violating timelines.
10. A group of 33 NorthStar anesthesia providers filed a lawsuit in December against Aetna and Cigna alleging $4.1 million in combined NSA underpayments, claiming the insurers either never paid or paid late without interest following IDR determinations that require payment within 30 days.
11. UnitedHealthcare filed a lawsuit in August against Radiology Partners and its Arizona affiliate Sonoran Radiology, alleging the companies misused the IDR process by routing in-network claims through Sonoran to make them appear out-of-network and initiating arbitration on tens of thousands of claims.
