The No Surprises Act, passed in 2020 and implemented in 2022, was designed to protect patients from unexpected out-of-network medical bills. It also established the federal independent dispute resolution (IDR) process, allowing out-of-network providers and health plans to resolve payment disputes when good-faith negotiations fail.
IDR was intended to function as a last-resort “safety valve”, but it has become a major operational and financial challenge for the healthcare system.
When the law was enacted, federal agencies estimated that the IDR process would be used about 17,000 times per year, with most disputes resolved through negotiation. Actual dispute volume has dwarfed those estimates.
From 2022 through 2025, 4.8 million IDR disputes were filed. In the second half of 2025 alone, nearly 1.4 million disputes were initiated — roughly 80 times what federal agencies projected for an entire year.
“IDR was not designed to become the default outcome for millions of claims,” said Maisie Weir, vice president of strategic solutions at Zelis. “The scale of activity has fundamentally changed what health plans need from their operations, technology and partners.”
Payers operations are under increasing strain.
The unexpected growth in IDR volume is creating significant pressure for health plans and third-party administrators (TPA).
In the last half of 2025, providers and facilities initiated 99.9% of disputes and prevailed in 85% of resolved cases. During that same period, health plans challenged 42% of disputes as potentially ineligible for IDR, while certified IDR entities ultimately determined that 19% were ineligible.
That gap illustrates the complexity of making eligibility determinations in a process governed by detailed regulatory, geographic, timing and claim-specific requirements. It also represents a substantial amount of administrative work occurring before the merits of a payment dispute are even considered.
For payers, every dispute can require claim research, eligibility analysis, document preparation, pricing review, deadline management and coordination among internal teams and external partners. At high volumes, those requirements can quickly overwhelm operations.
“These disputes are consuming time and resources across the healthcare system,” Ms. Weir said. “Payers and providers are devoting enormous effort to resolving threshold questions and payment disagreements that, in many cases, could have been addressed earlier in the claim life cycle.”
Existing IDR processes were not built for this scale
Few health plans and TPAs anticipated the volume or complexity of today’s IDR environment. Many initially managed disputes as an extension of existing claims, legal or payment integrity functions rather than as a dedicated operational discipline.
As volumes increased, plans often added staff, spreadsheets, workflow tools or point solutions to address immediate needs. Those measures may help manage individual tasks, but they do not always create a coordinated end-to-end process.
Teams may still be required to move between disconnected systems, reconcile inconsistent data, manually track deadlines and recreate claim histories. Expertise may also be distributed across claims operations, network management, legal, finance and vendor teams, making it difficult to maintain a consistent strategy.
“Managing IDR through disconnected tools, manual workflows and overstretched teams is no longer sustainable,” Ms. Weir said. “The challenge is not simply the number of disputes. It is the number of decisions, handoffs and deadlines associated with each one.”
Payers are now at an inflection point. The path forward is not limited to processing a larger number of disputes more quickly; it requires reconsidering how out-of-network claims are managed from the initial pricing decision through negotiation and, when necessary, arbitration.
The goal should be preventing avoidable disputes
Automation can help health plans manage IDR volume, but automating a fragmented process does not necessarily improve the process itself. It may simply accelerate existing handoffs, inconsistencies and rework. A stronger approach begins earlier.
Health plans can reduce avoidable IDR activity by identifying potential eligibility issues sooner, supporting defensible initial payment decisions and approaching open negotiations with better data.
“The strongest NSA strategies aren’t only about winning disputes,” Ms. Weir said. “They are about preventing unnecessary disputes, resolving appropriate cases during negotiation and developing payment positions that can be clearly supported when a case proceeds to arbitration.”
That requires a shift from reactive case management to a more proactive operating model. Instead of treating IDR as an isolated downstream function, payers can manage the full dispute resolution life cycle as a connected process.
That process may include:
Reviewing claims for potential eligibility concerns before or during open negotiations
- Identifying claims with a high likelihood of escalation
- Applying compliant pricing and settlement strategies
- Centralizing supporting documentation and claim history
- Prioritizing cases based on financial exposure, complexity and precedent
- Incorporating outcomes into future negotiation decisions
The objective is not to eliminate legitimate disputes. It is to ensure that the appropriate claims reach IDR and that the parties are equipped to resolve others earlier.
Intelligence must be applied across a claim life cycle
Artificial intelligence can support this operating model when it is integrated into the workflow rather than added to a single task at the end.
At the claim level, AI can help analyze large volumes of data, identify patterns, and surface possible eligibility issues and recommend next steps. It can also help teams prioritize work by distinguishing routine cases from those that require deeper review.
For example, an intelligent workflow may identify that a dispute requires additional eligibility analysis, recommend a potential settlement range or suggest an offer strategy based on claim characteristics or market information.
“Intelligence must be embedded across the process,” Ms. Weir said. “It should help inform decisions from early claim review and negotiation through arbitration preparation, rather than functioning as a separate tool that teams consult after most of the work has already occurred.”
This is where an AI-native approach differs from isolated automation. The value does not come from using AI for its own sake. It comes from using intelligence to connect decisions across the life cycle and continuously improve how future claims are handled.
AI can increase capacity, but human judgment remains essential
IDR involves consequential decisions that cannot be made solely through automation.
AI can analyze claims at scale and recognize patterns that may be difficult for an individual reviewer to identify. It can assemble information, flag exceptions and generate recommendations. However, experienced professionals are still needed to evaluate context, apply payer-specific policies and make accountable decisions.
That context may include a health plan’s history with a provider, local market dynamics, contractual considerations and the broader implications of a settlement or arbitration position.
Zelis uses agentic AI to provide support and expert review across the NSA workflow. Depending on the case, the system may surface an eligibility flag, propose a settlement range or recommend an offer strategy. Experts then assess those recommendations and determine the appropriate action.
“We view the model as AI-supported decision-making combined with human expertise, not AI replacing people,” Ms. Weir said. “Automation can handle data-intensive and administrative work, while qualified professionals retain control over material decisions and external submissions.”
The combination can also change how payer teams spend their time.
Instead of manually reconciling information across multiple systems, tracking routine tasks or researching every claim with the same level of intensity, teams can focus their attention on complex, high-value and high-risk cases.
That is particularly important in an environment where dispute volumes can fluctuate rapidly and specialized expertise is limited.
Managing NSA claims at scale requires a life cycle approach
The benefits of a connected model are best measured by more than arbitration outcomes alone.
In 2025, Zelis generated nearly $2.4 billion in savings on NSA claims, while approximately only 8% of those claims escalated to IDR. The results demonstrate the value of addressing pricing, negotiation and dispute management as parts of the same process rather than as separate activities.
When more claims can be resolved effectively before arbitration, payer teams can dedicate greater attention to disputes that present genuine legal, operational or financial complexity. Providers receive more consistent information, and certified IDR entities are less burdened by cases that may have been resolved earlier.
A life cycle approach can also give health plans greater visibility into why disputes occur.
Success should be measured across the full claim life cycle, including dispute avoidance, negotiation outcomes and arbitration performance.
Building a more sustainable dispute resolution system
The No Surprises Act’s core promise was to remove patients from the middle of out-of-network payment disputes. Fulfilling that promise requires a dispute resolution process that is also workable for the organizations responsible for administering it.
“Patients should not have to navigate these payments, but the system also has to be sustainable for payers and providers,” Ms. Weir said. “A more intelligent and coordinated process can reduce unnecessary friction while preserving a fair path for legitimate disputes.”
For payers, the next phase of NSA strategy will likely be shaped by their ability to connect technology, experience, and human expertise across the full claim life cycle.
The opportunity is not simply to resolve payments faster. It is to identify the right cases earlier, negotiate more effectively, defend payment decisions more consistently and prevent avoidable disputes from reaching IDR.
A healthier dispute resolution system can create more predictable costs, more focused operations and a clearer process for payers, providers and members alike.
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