No Surprises Act: What Has Changed for Providers — and Where the Real Risks Now Lie

The law designed to protect patients created a new arbitration economy. That same system is now drawing sustained attention from federal regulators, payers, and Congress — and the stakes for providers have shifted significantly.

What Happened to the IDR System

When the Independent Dispute Resolution (IDR) process launched in 2022, the federal government projected roughly 17,000 disputes per year. What actually happened: more than 3.3 million disputes were filed through May 2025, with nearly a million initiated in the first five months of 2025 alone.

Providers won more often than not — 85% of arbitration decisions in 2024 went their way. The median post-arbitration payment reached 459% of the Qualifying Payment Amount (QPA), up from 327% in 2023. Payers were required to pay more than $2.24 billion above in-network rates in 2023 and 2024 combined.

Why This Is Now a Risk, not Just an Opportunity

A high arbitration win rate led some providers to treat the IDR process as a reliable revenue channel with few constraints. Brookings Institution data published in April 2026 changed the picture: arbitration prices for imaging services reached 767% of average Medicare rates — compared to roughly 200% before the NSA was enacted. That scale of divergence has triggered concrete responses, not just commentary.

A joint analysis by AHIP and the Blue Cross Blue Shield Association covering 154 million insured individuals found that in 2024, 39% of disputes sent to arbitration were ineligible under the NSA — yet roughly half still resulted in mandatory payments. One BCBS company alone paid out nearly $257 million on ineligible claims through August 2025.

Enforcement Actions Already Underway

• UnitedHealthcare sued Radiology Partners, alleging systematic routing of in-network claims through a subsidiary to trigger IDR eligibility.
• Anthem Blue Cross sued 11 Prime Healthcare hospitals in California for flooding the IDR process with over 6,000 ineligible claims.
• BCBS Texas sued billing company Zotec Partners for knowingly initiating thousands of ineligible disputes.
• Elevance Health introduced a 10% penalty for hospitals using out-of-network providers, citing a 40% increase in IDR volume in 2025 — drawing a congressional inquiry.
• Congress is actively debating reforms: proposals include stronger QPA weighting and caps on the number of filings a single entity can submit.

Where Your Exposure Actually Sits

Three categories of vulnerability are attracting the most scrutiny from payers and auditors right now:

• Ineligible claims. Medicare Advantage patients, service types outside NSA scope, and procedural misclassifications can all render a claim ineligible after the fact — with clawback exposure on payments already received.
• Indefensible QPA positions. Arbitrators evaluate your proposed payment amount against documented market norms. Offers that cannot be supported by comparable contracted rates or regional benchmarks create bad-faith risk, not just losing outcomes.
• Documentation gaps. Contracts, clinical records, and prior payment history are what arbitrators and auditors examine first. Missing documentation weakens your position even in cases that would otherwise be winnable.

What to Review Now

• Screen your existing IDR pipeline for NSA eligibility before an audit raises the question — not after.
• Verify how QPA is calculated and documented for your specialties and geographic market.
• Confirm that clinical documentation on disputed cases would withstand external review.
• Assess whether your organization falls into the categories under the most pressure: radiology, emergency medicine, anesthesiology, and large investor-affiliated groups are explicitly named in current litigation and research.
• Monitor proposed legislative changes closely — QPA reweighting and filing caps could materially alter the arbitration calculus for high-volume filers.