Providers are winning the majority of independent dispute resolution cases under the No Surprises Act, but recent court rulings have limited enforcement of awards and new lawsuits allege providers are misusing the IDR process for financial gain.
The NSA was designed to prevent surprise billing by establishing the IDR process for payment disputes between insurers and out-of-network providers, mandating that disagreements be resolved through a neutral third-party arbitrator.
Five No Surprises Act updates:
1. In the first half of 2024, providers won around 83-88% of IDR cases, often securing much higher amounts than insurers, with the median prevailing offer in some cases reaching 447% of the qualifying payment amount, according to a June study published in Health Affairs. The IDR process remains concentrated in Texas, Florida and Arizona and among large provider groups, with third-party companies emerging to help smaller providers navigate the process.
2. In June, the Fifth Circuit Court of Appeals sided with insurers over air ambulance companies, ruling that the NSA does not grant a private right of action to enforce IDR awards in court, unless there is clear evidence of fraud or misconduct. The court also ruled that third-party IDR entities are immune from lawsuits, which provides insurers with legal protection against disputes over arbitration outcomes. Prior to the decision, providers had filed hundreds of lawsuits over unpaid IDR arbitration awards, with federal courts split on whether the NSA grants a right to confirm awards in court.
3. In May, Elevance Health’s Blue Cross Blue Shield of Georgia sued HaloMD, Hospitalist Medicine Physicians of Georgia and Sound Physicians Emergency Medicine of Georgia, alleging the three organizations exploited the IDR process for financial gain. The lawsuit claims that the companies knowingly submitted thousands of ineligible disputes in an effort to receive inflated reimbursement payments.
4. In July, Elevance executives discussed the Georgia lawsuit with investors amid what they described as “inappropriate use” of the IDR process by providers.
“We’ve seen out-of-network providers and their billing partners submit thousands of disputes, sometimes hundreds in a single day, and our payment request can be significantly inflated, which is costing the entire healthcare system,” CEO Gail Boudreaux said. “We fully support the Act, but we also know that it has to be implemented appropriately.”
5. In April, a New York federal judge dismissed an antitrust lawsuit against UnitedHealthcare and MultiPlan (now Claritev) that alleged the companies conspired to reduce reimbursement rates to Long Island Anesthesiologists by more than 80% after the NSA took effect in January 2022.
