The No Surprises Act has delivered on one of its central promises: fewer surprise medical bills. A survey from AHIP and the Blue Cross Blue Shield Association found that the NSA protected patients from nearly 20 million potential surprise bills in 2024 alone.
But the law has not worked as intended in every respect. For payers, the independent dispute resolution process the NSA established — a federal arbitration pathway for settling payment on eligible, out-of-network claims — has proven far more burdensome than Congress anticipated.
Providers initiate the vast majority of disputes, and for many, IDR has become a routine part of the reimbursement process rather than an exception. The result is a caseload well beyond what regulators anticipated, and payers nationwide are absorbing the administrative strain and added cost that come with it. Managing claims efficiently while maintaining long-term sustainability is harder than ever.
As the market-leading independent, non-payer IDR administrator by volume, Claritev works with health plans and payers across the country. That vantage point has surfaced a consistent pattern: effective NSA management comes down to striking the right balance between operational discipline, organizational flexibility and process efficiency.
Skyrocketing disputes are reshaping reimbursement
When the NSA was enacted, CMS projected that roughly 22,000 disputes per year would move through the IDR process, which was designed to resolve legitimate, material disagreements between providers and payers.
The reality looks nothing like that projection. In 2025, more than 2.5 million disputes were filed through IDR, up from 1.5 million in 2024. Providers prevailed in roughly 85% of cases, with a median award of more than four times the qualifying payment amount.
Together, that volume and those award amounts point to a shift in how IDR functions in practice. What policymakers designed as an occasional backstop has become a regular and financially viable part of how out-of-network claims get resolved.
For many providers, the economics increasingly favor remaining out of network and pursuing arbitration over signing a contract. As Jennifer Forcash, Claritev’s assistant vice president of innovation and solution lifecycle, explained: “Providers who can reliably beat QPA by those multiples in arbitration have little incentive to sign network contract rates that are anywhere near the market median.”
When providers do come to the table, they arrive with more leverage to push for higher reimbursement rates. That creates a compounding problem; as the QPA is derived from contracted rates, every upward renegotiation pulls the benchmark itself higher.
Sophisticated private equity-backed emergency medicine, anesthesiology, radiology and surgical groups have taken note, building dedicated arbitration, legal and revenue cycle infrastructure around IDR.
“The overall impact is that IDR arbitration is starting to function less like a dispute resolution mechanism of last resort and more like a market price-setting mechanism,” Ms. Forcash said.
Payers need operational excellence across the dispute lifecycle
On top of mounting disputes and growing awards, payers are also contending with new requirements under the Federal Independent Dispute Resolution Operations Final Rule issued in May 2026. The rule pushes the ecosystem away from manual, discretion-heavy processes toward a more standardized, auditable and technology-enabled model.
IDR activities that once relied on interpretation and manual review now carry clearer standards and better-defined workflows. Documentation and audit readiness have become core operational requirements rather than back-office tasks.
For many payers, adapting is the hard part. Most already hold the data needed to support the required documentation and audit work, but Claritev has found that extracting the right information and applying it correctly is often where teams stall.
As the bar for operational excellence rises, health plans and payers need stronger technology, reporting, audit support and dispute lifecycle management. Arbitration workflow orchestration, for instance, must be flexible enough to absorb high-volume filing spikes — and those spikes aren’t always accidental, according to Ms. Forcash.
“Some providers intentionally concentrate filings on Fridays, weekends and around federal holidays because they know that payers’ staff coverage is thinner,” she said.
Priority one for payers: Reducing ineligible claims
A significant driver of increasing dispute volume is how many of the claims providers submit are ineligible in the first place. About half of the disputes Claritev manages for payers are flagged as ineligible for one reason or another.
For organizations handling NSA management on their own, identifying and acting on those claims can be daunting — a missed opportunity, because nothing does more to reduce unnecessary IDR activity and relieve administrative burden than screening them out early.
Without automated eligibility screening deployed at scale, many ineligible claims move forward simply because teams can’t complete the reviews in time. “The timelines are tight. Organizations must be able to assess and object before claims move into dispute resolution,” Ms. Forcash said.
Eligibility screening is a strong first step, but it works best alongside other measures: tightening notice and timing controls, auditing recurring sources of invalid submissions and clarifying state versus federal routing.
Keeping eligible claims out of IDR
Once payers stem the flow of ineligible claims, the next priority is keeping eligible ones out of the IDR process altogether.
Drawing on its work with payer clients, Claritev has identified several effective levers — among them, using complementary network and standing rate agreements where available.
In one recent analysis for a payer client, Claritev found that nearly half the claims that went through IDR could have been priced through a Claritev network contract. The organization could have avoided IDR awards far exceeding the QPA, along with the administrative and arbitrator fees those disputes carried.” Proactive rate agreements made with providers pick up out-of-network claims at negotiated rates well below the IDR multiples we’re seeing,” Ms. Forcash said.
Initial payment and post-payment negotiation offers deserve the same care. Rather than applying a single enterprisewide threshold or reimbursement policy, payers are better served by provider- and procedure-specific, benchmark-driven offers. Those offers carry more weight when they include dynamic ceiling logic informed by escalation probability analytics, provider tendencies and IDR patterns.
Partnering for NSA success
At more than 2.5 million disputes a year, throughput and consistency at scale matter as much as arbitration strategy. The organizations that struggle are the ones still running manual, fragmented workflows.
“Success depends on having scalable workflows and strong governance processes,” Ms. Forcash said. “That extends beyond payers to their vendor partners, as well. Using an operating model designed for the initially predicted 22,000 disputes simply can’t keep pace with today’s volumes, timelines and documentation standards.”
The most underappreciated risk isn’t the arbitration decision. It’s the administrative friction upstream and downstream of it. A scalable, data-driven operating model delivers value by addressing ineligible claims, the fee structure and the documentation burden.
Managing NSA effectively requires a portfolio of capabilities aimed at keeping claims out of IDR — scalability and operational efficiency, but also robust analytics and predictive modeling. As IDR volume and complexity grow, many payers are turning to Claritev’s end-to-end NSA services.
Newly released 2025 data from CMS shows that Claritev handled more federal IDR claims than any other non-payer participant. Claritev clients’ offers prevailed in 20% of applicable determinations in 2025, compared with 12% industrywide, and that rate climbed to 24% in the fourth quarter.
“We have worked in this space since day one and we continue to invest in NSA year-over-year,” Ms. Forcash said. “When legislation changes, we have teams in place with the knowledge, expertise and technology to deal with it. We’re not just a vendor. We’re a trusted partner that delivers peace of mind to clients.”
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