By Jack Hoadley, Kennah Watts, and Zachary Baron
The No Surprises Act (NSA) protects customers from shock out-of-network (OON) billing by banning suppliers and amenities from steadiness billing customers for a lot of facility-based OON medical providers. Companies topic to the regulation embody most emergency providers, non-emergency providers from OON suppliers at in-network amenities, and providers from OON air ambulance suppliers.
Below the regulation, the payer should make a well timed fee (or a denial of protection) to the OON supplier. If the supplier finds the fee quantity insufficient and the events don’t privately attain an settlement, both get together can request an unbiased dispute decision (IDR), during which a third-party arbitrator (“IDR entity”) binds each events to both the plan or supplier supply.
In 2024, in compliance with NSA necessities, the related federal companies launched public use information (PUFs) with knowledge on the resolved IDR instances for 2023. In March 2025, the companies launched PUFs for the primary two quarters of 2024. These information embody info on the supplier and payer, in addition to supply quantities from every get together––expressed as a share of a qualifying fee quantity (QPA), the inflation-adjusted median charge paid by a selected insurer in 2019 to its contracted in-network suppliers, based mostly on insurance coverage sort and geographic location. The information additionally embody info on the prevailing supply, as decided by the IDR entity.
On this article, we construct on our findings from 2023 with evaluation from the primary two quarters of 2024. We illustrate traits within the IDR course of throughout supplier and payer sorts, supply quantities, geographic areas, IDR entities, and extra. We additionally discover potential implications for the long run use and price of the IDR course of. As related, we share findings from the companies’ supplemental tables, from our personal evaluation of the PUFs, and from discussions with stakeholders.
Speedy Charges Of New Case Filings; Extra Choices Rising From IDR Entities
The quantity of filed IDR instances remained excessive. The six-month whole for filed instances (586,581) in Q1 and Q2 of 2024 is almost as excessive as all of 2023 (657,040 filed instances), although this can be partly as a consequence of durations in 2023 when the IDR portal was suspended.
Exhibit 1. Variety of Filed IDR Instances and Share Initiated by Supplier Teams, Q1-This autumn 2023 and Q1-Q2 2024
Supply: Authors’ evaluation of Federal IDR Supplemental Tables for 2023 and 2024
The speed of filed instances challenged as ineligible was larger in Q1 and Q2 of 2024 (45 %) than in all of 2023 (37 %), however the charge of closed instances later discovered ineligible was considerably decrease: about 18 % in 2024 versus 22 % in 2023. Instances could also be ineligible based mostly on the dates of service, whether or not a case is roofed by the NSA, or the necessity to undergo a state fee willpower course of in sure states.
In 2024, the tempo of IDR entity decision-making accelerated considerably. About 335,000 fee determinations had been made in Q1 and Q2 of 2024, in comparison with about 200,000 instances in all of 2023. The quantity within the second quarter of 2024 was additionally properly above that within the first quarter. Notably, about one in six determinations are made in instances the place just one get together submitted a suggestion—a charge that has remained typically regular from 2023 to 2024. Discussions with stakeholders urged that this final result could also be the results of plans being overwhelmed by case quantity and unable to reply earlier than deadlines.
Instances Stay Concentrated In A Few States
IDR use remained extremely concentrated by geography. States with excessive volumes of resolved instances had been typically the identical as in 2023: Texas, Florida, Arizona, Tennessee, Georgia, New Jersey, and New York. Against this, a number of large-population states (Maryland, Massachusetts, and Washington) had fewer than 2,000 resolved instances within the first two quarters of 2024.
Suppliers had been most profitable in Texas, Florida, Arizona, and Virginia, with win charges between 89 % and 91 % of resolved cased in Q1 of 2024. This geographic focus is probably going considerably attributable to excessive concentrations of the supplier organizations that almost all often used IDR. For instance, throughout most quarters, greater than half of the instances in Texas concerned Radiology Companions affiliated suppliers. Equally, two-thirds of Tennessee and Florida instances concerned Workforce Well being.
Suppliers Proceed To See Extra Success Than Plans
Suppliers proceed to win way more usually and at a lot larger supply quantities than plans. In 2023, the speed of suppliers prevailing rose from 70 % of resolved instances in Q1 to 87 % in This autumn. Charges in 2024 matched the latter ranges: suppliers received 88 % and 83 % of resolved instances in Q1 and Q2, respectively (Exhibit 2).
Exhibit 2. P.c of Resolved IDR Instances Gained by Suppliers, Q1-This autumn 2023 and Q1-Q2 2024
Supply: Authors’ evaluation of Federal IDR PUFs, Reporting Yr 2023 and 2024.
Not solely do suppliers win way more usually, however their prevailing gives are a lot larger than plans. In Q1 of 2024, the median prevailing supplier supply was 383 % of QPA. This rose almost 70 share factors in Q2, with a median prevailing supplier supply of 447 % of QPA. Against this, the comparable charges in 2023 had been between 320 % and 350 %. In instances the place plans prevailed, their median supply quantity was a lot decrease: 105 % of QPA in each Q1 and Q2 of 2024.
Massive Supplier Teams Proceed To Prevail At Excessive Charges; Third-Get together Entities Emerge
As in 2023, resolved IDR instances had been predominantly from just a few giant supplier organizations – principally backed by personal fairness. Radiology Companions was probably the most frequent consumer of IDR in Q1 and Q2 of 2024, adopted by Workforce Well being, SCP Well being, AGS Well being, and HaloMD. Mixed, these 5 organizations account for almost two-thirds (63 %) of resolved instances (Exhibit 3).
Exhibit 3. Share of Resolved IDR Instances by High Supplier Organizations, Q1-Q2 2024
Supply: Authors’ evaluation of Federal IDR PUFs, Reporting Yr 2024.
Along with a excessive quantity of instances, these prime 5 supplier organizations received the overwhelming majority of their disputes, with supply quantities at the least two occasions larger than QPA. Radiology Companions considerably outmatched different supplier teams, with a median prevailing supply at 631 % of QPA and 610 % of QPA within the first half of 2024.
Whereas the exercise degree of Radiology Companions, Workforce Well being, SCP Well being, and AGS Well being remained comparatively secure from 2023 to 2024, HaloMD has emerged as a frequent participant in IDR instances. In 2023, HaloMD appeared in just one % of resolved disputes, whereas in Q2 of 2024, HaloMD initiated 10 % of disputes. HaloMD’s prevailing gives elevated considerably as properly: in Q1 of 2023, the group prevailed in 17 % of resolved instances, however their win charge steadily elevated to 84 % in This autumn of 2023. This success charge seems secure, reaching 89 % and 81 % in Q1 and Q2 of 2024.
HaloMD was particularly created “to be the main supplier of IDR providers.” HaloMD illustrates the rise of revenue enhancing middlemen centered on the IDR course of. Whereas giant supplier organizations like Radiology Companions and Workforce Well being have the interior sources to handle disputes on behalf of their suppliers, HaloMD and different third-party organizations can tackle the executive burden for smaller suppliers and supply them a larger alternative to interact in IDR. As a supplier group acquainted with the IDR course of wrote in a earlier Forefront piece, “smaller practices have much less skill to entry IDR than do bigger, well-capitalized organizations.” This development could be altering with the rise of IDR-specific middlemen.
Emergency And Radiology Companies Account For Two-Thirds Of Resolved IDR Instances
The median prevailing gives relative to QPA in Q1 and Q2 of 2024, by supplier specialty, typically match or exceed these in 2023 (Exhibit 4). For many specialties, the median share of QPA grew throughout the 4 quarters of 2023.
Exhibit 4. Median Prevailing Provide amongst Resolved IDR Instances as P.c of QPA by Specialty, Q1-This autumn 2023 and Q1-Q2 2024
Supply: Authors’ evaluation of Federal IDR PUFs, Reporting Yr 2023 and 2024.
Radiology and emergency providers are the 2 specialties with the very best quantity of resolved instances, accounting for about two-thirds of all determinations (not proven). Within the first half of 2024, the median prevailing supply for emergency providers was 257 % of QPA, a greater than 30 share level improve from 224 % in This autumn of 2023. Radiology providers skilled an identical improve in win quantities: within the first half of 2024, the median prevailing supply in radiology instances was 40 share factors greater than the top of 2023 (600 % QPA and 559 % QPA, respectively). These specialties are carefully correlated to sure supplier teams. For instance, Radiology Companions accounts for almost all of radiology instances, whereas Workforce Well being, SCP Well being, and Envision symbolize properly over half of all emergency instances.
Neurology and surgical procedure, although a smaller quantity (about 9 % of resolved instances in 2024), received a lot larger awards than radiology or emergency providers. In Q1 of 2024, the median prevailing get together supply for neurology was 1222 % of QPA, adopted by 1178 % in Q2. The median prevailing get together supply for surgical procedure was 1818 % of QPA in Q1 and 1716 % of QPA in Q2.
Plan Provides Minimally Enhance; Win Charges Stay Low
Plan success in IDR is mostly related throughout 2023 and 2024. In 2023, the speed of plans prevailed declined from 28 % of resolved instances in Q1 to fifteen % in This autumn. Outcomes from 2024 are related: plans received 14 % of resolved instances in Q1 and 18 % in Q2. As beforehand acknowledged, in instances the place plans prevailed, the median prevailing supply quantity was 105 % in each quarters of 2024—a small, however not insignificant, improve of 5 % from 2023. This shift may point out some effort by plans to answer their historical past of shedding IDR instances.
In Q1 and Q2 of 2024, the majority of resolved IDR instances concerned just a few giant plans as recipients of instances filed by suppliers. United Healthcare, Aetna, HCSC, and Anthem accounted for 2 thirds of instances. By one nationwide measure, these 4 firms account for almost half of the nationwide insurer market.
Third get together claims administration firms account for at the least a fifth of resolved instances. MultiPlan (now Claritev) and Clear Well being Methods are the 2 largest entities (13 % and seven %, respectively). The elevated quantity of instances attributable to administration firms might be proof that plans, like suppliers, additionally leverage intermediaries to handle their disputes and maximize their OON claims income.
Important Variation Amongst IDR Entity Quantity and Choices
The tempo of IDR entity decision-making has considerably accelerated in 2024, yielding hope that case backlogs will probably be decreased. However our conversations with stakeholders have indicated one other potential concern: that some IDR entities might determine in favor of suppliers considerably greater than others. This concern is supported by our evaluation of PUF knowledge. We discover that 4 IDR entities made choices favoring suppliers in over 90 % of their instances in 2024, whereas one entity favored suppliers in solely one-third of its instances. Ideally, the general decision-making sample ought to be related throughout all IDREs, so will probably be essential to know why variations exist.
Litigation And The IDR Course of
Litigation additionally continues to form the implementation of the NSA. A number of ongoing instances and appeals may have a big affect on the success of the arbitration course of and its function in affecting well being care prices extra broadly.
Suppliers, led by the Texas Medical Affiliation, efficiently leveraged litigation to block previous efforts by the Biden Administration to place modest guardrails in place regarding how arbitration entities ought to take into account and weigh the related statutory components when deciding between two gives. However suppliers haven’t been profitable in instances throughout the board. The Biden Administration received an enchantment earlier than a Fifth Circuit panel final fall in an additional problem introduced by the Texas Medical Affiliation and air ambulance suppliers (generally known as “TMA III”) regarding sure regulatory provisions outlining the calculation of the QPA. That call overturned a lot (although not all) of the decrease courtroom’s determination siding with the suppliers. However authorized fights over the QPA methodology have nonetheless not concluded. The suppliers requested the total Fifth Circuit to reverse the panel—and on Might 30, 2025, the fifth Circuit issued an order vacating the earlier opinion and directing that the case be reheard en banc (by all lively judges on the courtroom). Briefing will run via early September 2025 (with oral argument to be scheduled subsequently). Whereas sure enforcement discretion associated to the QPA stays in impact till August 1, 2025, future company steering could also be wanted to make clear the quick affect of this improvement on sufferers and the arbitration course of.
In one other case on pause in federal district courtroom in Kentucky, suppliers challenged a number of NSA regulatory provisions below the Administrative Process Act and the Takings Clause of the Fifth Modification. Varied different ongoing instances relate to efforts to overturn sure arbitration awards or compel fee by a celebration to arbitration. Some contain instances introduced by suppliers in opposition to insurers and arbitration entities straight. The leads to such instances have been blended so far, with appeals filed within the Fifth and Eleventh Circuits. The Division of Justice (DOJ), via amicus briefs, has urged courts to search out that arbitration entities themselves are usually not correct events to such instances—arguing that such litigation in the end may end in “thwarting Congress’s need to create a low-cost, environment friendly” arbitration course of. As to alleged nonpayment by events to the arbitration course of as soon as IDR fee determinations have been made, DOJ has additionally advised courts that if events can not acquire aid in courts for such nonpayment, “one of many [NSA]’s core options could be annoyed, upending Congress’s scheme.”
Insurers have additionally filed a number of lawsuits alleging supplier abuse of the IDR course of via submitting ineligible instances with the intention to acquire improper fee charges. Such instances stay within the early levels, but when they proceed, discovery may shed extra mild on how sure suppliers are strategically leveraging the IDR course of.
What Does It All Imply?
The evaluation of resolved IDR instances reveals that suppliers are sometimes turning to IDR reasonably than accepting preliminary plan funds. Though the vast majority of instances are deemed eligible for the IDR course of, plans are difficult the eligibility of almost half the instances that suppliers file.
These excessive numbers spotlight the disconnect between the 2 sides as they debate what constitutes an affordable fee for OON providers. Suppliers consider the excessive quantity of IDR disputes displays insufficient fee by plans, exacerbated by potential manipulation of the QPA. Plans reply that their QPAs are correct and that suppliers ought to be prepared to just accept funds that align carefully with in-network charges. Amidst this debate, the federal authorities has launched the outcomes of 1 QPA audit, and extra audits may shed some mild on the contrasting claims round QPAs.
Findings from the IDR knowledge increase two essential considerations. First, IDR instances are considerably concentrated amongst only a few supplier organizations. Second, middlemen organizations are more and more frequent customers of the system. On one hand, intermediary organizations may prolong entry to the IDR course of to suppliers who are usually not a part of giant organizations and thus face administrative burdens in utilizing the system. However, such organizations might contribute to larger general case quantity, rising prices for the entire well being system.
Moreover, suppliers proceed to have a excessive share of instances determined of their favor, leading to giant fee awards. Suppliers make the case that their gives are merely extra affordable and that arbitrators agree. There are additionally some anecdotal studies that plans have been much less aggressive than suppliers in placing their arguments in entrance of the IDR entities. Because the federal companies famous in background supplies: “Whereas well being plans and issuers usually benchmarked their gives to the QPA, suppliers, amenities, and air ambulance service suppliers usually benchmarked their gives to previous OON fee quantities with the disputing plan or issuers and previous in-network charges with both the disputing plan or issuer, or with a unique plan or issuer in the identical state.” Plans have raised considerations that historic benchmarks might replicate circumstances earlier than passage of the NSA when some plans paid full billed prices to make sure that prices weren’t handed alongside to customers. With out public reporting of the rationale for IDR entity choices, observers can solely speculate how a lot historic funds affect the choices.
The excessive quantity of IDR instances, together with the prevalence of ineligible instances, might be tempered if proposed guidelines for course of enhancements had been finalized and if ongoing litigation over the QPA methodology was resolved. Higher training, coaching, and oversight of IDR entity decision-making may additionally assist scale back a number of the uncertainties within the course of.
The longer-term affect of IDR choices on well being prices remains to be principally unknown. On the floor, it appears that evidently the excessive supplier profitable charge and the scale of the funds awarded would increase well being prices and plan premiums. However the magnitude of any such improve is proscribed by the share of all well being care claims represented by the IDR instances. Moreover, stakeholder claims diverge wildly on whether or not we’ve got seen an affect of the NSA on the scale of supplier networks or on negotiations over the charges paid to suppliers.
Notably, nothing in these findings from the IDR course of raises questions in regards to the effectiveness of the NSA in stopping customers from experiencing shock payments within the situations the place the NSA created protections. The difficulty stays whether or not the regulation’s mechanism for establishing an affordable fee from plans to suppliers is working. To the extent it’s not, a key query is whether or not there are value implications for the well being care system as a complete and for customers specifically.
To study extra about variation within the IDR course of and potential value implications, learn the just lately revealed companion piece: No Surprises Act Arbitrators Fluctuate Considerably In Their Determination Making Patterns.
Jack Hoadley, Kennah Watts, and Zachary Baron “Impartial Dispute Decision Course of 2024 Information: Excessive Quantity, Extra Supplier Wins” June 11, 2025, https://www.healthaffairs.org/content material/forefront/independent-dispute-resolution-process-2024-data-high-volume-more-provider-wins. Copyright © 2025 Well being Affairs by Mission HOPE – The Folks-to-Folks Well being Basis, Inc.
