The No Surprises Act IDR Guide
A comprehensive analysis of the Independent Dispute Resolution process, featuring data from Brookings, Georgetown, and USC research, plus insights from the industry's leading policy experts.
3.3M
Disputes Filed
85%
Provider Win Rate
$5B
System Costs
192×
Cumulative / annual estimate
Introduction
Understanding the law that changed healthcare payments
Historical research guide: the original narrative was compiled in January 2026 and includes earlier studies and litigation summaries. It is not a current deadline or legal-status reference. For current source-linked process answers, see IDR eligibility, documents, and fees. Statistical source dates describe the underlying research, not a new review of the entire guide.
What is the No Surprises Act?
The No Surprises Act (NSA) is landmark federal legislation that took effect on January 1, 2022. It was designed to protect patients from unexpected medical bills, commonly known as "surprise bills," that occur when patients unknowingly receive care from out-of-network providers.
Before the NSA, patients could receive massive bills for emergency services or when treated by out-of-network providers at in-network facilities. The NSA shifted this burden away from patients and created a system for providers and payers to resolve payment disputes directly.
IDR was supposed to serve as a backstop but it was being used in some states as mechanisms for certain provider types to stay out of network and go to IDR to get the payment levels they would like.
What is Independent Dispute Resolution?
Independent Dispute Resolution (IDR) is the arbitration process established by the No Surprises Act to resolve payment disputes between healthcare providers and insurance companies for out-of-network services.
Two offers. One selection.
Adjust the example offers, then choose a hypothetical outcome. This illustrates final-offer selection—not how an arbitrator weighs evidence.
The controls do not predict a decision or recommend an offer.
Why IDR Matters for Healthcare
The Congressional Budget Office (CBO) originally projected that the NSA would have a modest dampening effect on health costs and premiums, estimating premium decreases of 0.5% to 1%. The reality has been dramatically different.
There is a realistic possibility that the NSA will raise in-network prices and premiums, the opposite of what CBO predicted at enactment.
State of IDR: January 2026
Four years into implementation, the IDR system has evolved into something few predicted. Here's where we stand:
What's Working
- • Patients protected from surprise bills
- • 85% of disputes resolved
- • Provider win rate consistently high
- • Backlog decreasing (down to ~500K)
What's Concerning
- • Dispute volume far above annual projections
- • $5B in system costs (2022 to 2024)
- • PE firms dominating outcomes
- • Enforcement uncertainty after court split
IDR By The Numbers
The data that defines the dispute landscape
Volume Statistics
3,324,051
disputes filed from mid-2022 through May 2025
When CMS released regulations for the No Surprises Act, they projected approximately 17,333 disputes annually. The reality has been staggering.
IDR Volume: Projection vs. Reality
| Original CMS annual estimate | 17,333 disputes |
| Actual filed (mid-2022 to May 2025) | 3,324,051 disputes |
| Cumulative total ÷ annual estimate | 192× |
| First 9 months alone | ~190,000 (10× annual projection) |
Source: Georgetown CHIR analysis, May 2025. The 192× ratio compares a multi-year total with a one-year estimate; it is not an annual increase.
The volume of IDR disputes continues to surpass agency estimates by millions.
The $5 Billion Problem
$5B
total IDR system costs from 2022 to 2024
Georgetown CHIR's landmark analysis revealed the true cost of the IDR system. These costs are ultimately passed on to consumers through higher premiums and cost-sharing.
What makes up the roughly $5B total?
Select a category to inspect its contribution. Percentages are calculated from the amounts reported below.
Payments above QPA in the analysis. This is not an administrative fee.
Reported amounts total $5.024B; rounding explains the “$5B” headline. Source: Hoadley & Watts, Health Affairs Forefront, August 2025, as cited in this guide.
Key Point
Outcome Statistics
Provider win rates have remained consistently high and have actually increased over time.
81%
Provider Win Rate
2023
85%
Provider Win Rate
2024
More striking is how much providers are receiving relative to the Qualifying Payment Amount (QPA):
327%
Median Determination
of QPA, 2023
459%
Median Determination
of QPA, Q4 2024
Providers are submitting relatively high offers and IDR entities are selecting the provider's offer more than 75% of the time.
Timeline Reality
The law requires IDR decisions within 30 business days. Reality tells a different story.
30
Statutory deadline (days)
81
Actual median, Q4 2024 (days)
Peak: 96 days in earlier periods
Eligibility & Coverage
Which claims qualify for IDR
Eligible Services
Not every out-of-network claim qualifies for IDR. The NSA covers specific categories of services.
Emergency Services
ER visits, stabilization, post-stabilization care when transfer impossible
Air Ambulance
Air ambulance services from OON providers (NOT ground ambulance)
Ancillary Services
OON providers at in-network facilities (anesthesia, radiology, pathology)
Excluded Claims
Warning
Claims NOT Eligible for Federal IDR:
- Ground ambulance services
- Medicare and Medicaid claims
- Services where patient signed valid OON consent waiver
- Claims in states with All-Payer Model (Maryland)
- Coverage disputes (only payment amount disputes qualify)
State vs Federal Jurisdiction
The federal IDR process applies to most commercial insurance plans, but 22 states have their own "specified state laws" that may apply instead.
Pro Tip
The IDR Process
Step by step from dispute to decision
Process Overview
The IDR process follows a structured timeline with specific requirements at each stage. Understanding each step is essential for maximizing your success rate.
Step-by-Step Walkthrough
Follow the case through each stage.
Initial Payment
Payer issues initial payment (or denial) for OON claim. This starts the window to initiate open negotiation.
Triggers timelineThese are the guide’s summarized stages, not a deadline calculator. Rules and exceptions can change. Check the current CMS process guidance for a specific dispute.
Critical Deadlines
Warning
Deadline Quick Reference
30
Start negotiation
After payment
4
Initiate IDR
Critical!
10
Submit offers
With evidence
30
Payment due
After decision
Understanding QPA
The controversial benchmark at the center of IDR
What is QPA?
The Qualifying Payment Amount (QPA) is a key benchmark in the IDR process. It represents the median contracted rate the payer has negotiated with in-network providers for the same or similar service in the same geographic area.
Key Point
How QPA is Calculated
QPA Calculation Methodology
- 1
Identify relevant contracts
All in-network contracts for the service code
- 2
Define geographic region
Same metropolitan statistical area (MSA) or state
- 3
Calculate median
Median contracted rate under the applicable QPA methodology
- 4
Annual indexing
QPA is recalculated annually using CPI-U inflation
QPA Controversies
QPA methodology has been one of the most litigated aspects of the No Surprises Act. The Texas Medical Association's lawsuits have fundamentally challenged how QPA is calculated and used.
The federal rules permit insurers to include 'ghost rates' in their QPA calculations: contract rates with physicians who don't actually provide the particular health service.
TMA III Allegations: QPA Problems
- Contract rates for services never actually provided
- Rates from physicians not in same/similar specialty
- Amounts excluding contingent payments (bonuses, risk-sharing)
- Rates from other self-insured plans
TMA III en banc hearing scheduled for 2025; outcome could reshape QPA rules
Winning Strategies
What separates successful cases from failures
Key Success Factors
With providers winning approximately 85% of decided IDR cases, success is achievable but not automatic. Research consistently shows certain factors correlate with better outcomes.
Verified Benchmark Data
CriticalUse actual payment data from similar providers, not just Medicare rates or billed charges
Complete Documentation
CriticalEvery required element present and properly formatted. Missing docs give payers easy wins
Strategic Case Selection
HighFocus resources on cases with strong evidence; not every eligible claim should go to IDR
Clear Presentation
HighMake it easy for the arbitrator to understand your argument and find supporting evidence
Evidence Requirements
Arbitrators are legally required to consider specific categories of evidence. Your submission should address each of these factors comprehensively.
| Factor | What to Include |
|---|---|
| Provider Qualifications | Training, certifications, experience, subspecialty expertise |
| Market Share | Provider's presence and reputation in the geographic region |
| Patient Acuity | Complexity of condition, comorbidities, severity of presentation |
| Service Complexity | Technical difficulty, time required, resources utilized |
| Prior Negotiations | History of good faith contract negotiations with the payer |
Strategic Case Selection
Not every eligible claim should go to IDR. Research from Georgetown CHIR shows that many disputes are filed without adequate evidence or case selection strategy.
Little evidence that rank-and-file emergency physicians, radiologists, and anesthesiologists are using the system. Four organizations accounted for ~2/3 of cases in Q2 2023.
Clearest reports a 94% platform win rate on IDR cases
Company-reported metric. Eligibility and outcomes depend on the facts of each dispute.
Private Equity & IDR
The outsized role of PE-backed providers
PE Dominance in IDR
One of the most striking findings from academic research is the disproportionate role of private equity-backed provider groups in the IDR system.
The awards received through the NSA's independent dispute resolution process largely arise from disputes that are primarily initiated and won by private-equity-backed providers.
The Numbers
90%
PE-Backed Win Rate
vs. 39% for other ER groups
+63%
PE Premium
higher payments relative to QPA
Top IDR Initiators by Volume
| Organization | Share of Disputes |
|---|---|
| Radiology Partners | 28% |
| TeamHealth | 15% |
| Envision Healthcare | ~8% |
| SCP Health | ~8% |
| Top 5 providers combined | 59% |
Source: Adler, Fiedler et al., Brookings 2024
Rise of Middlemen
A new development in the IDR landscape is the emergence of third-party IDR services that file disputes on behalf of providers.
HaloMD Growth
1%
of disputes, 2023
10%
of disputes, Q2 2024
Middlemen could give greater access to smaller provider organizations, but could also be driving higher volume of cases that increases systemwide costs.
Legal Landscape
How litigation has reshaped IDR rules
TMA Lawsuit Victories: 4-0
The Texas Medical Association (TMA) has been the most consequential player in shaping IDR rules through litigation. They've won all four major lawsuits challenging the federal regulations.
Challenged "rebuttable presumption" favoring QPA
Court struck down presumption; said it improperly tilted scales toward insurers
Fundamental shift in how IDR entities weigh factors
August 2022 final rule still required "outsized weight" to QPA
Court vacated provisions favoring QPA (February 2023)
QPA no longer presumptive winner; Fifth Circuit affirmed August 2024
QPA calculation methodology allows "ghost rates" and manipulations
District court invalidated four provisions; Fifth Circuit panel reversed in part
En banc hearing granted May 2025; could take ~1 year
600% fee hike ($50 → $350) and narrow batching rules
Court struck down fee increase; vacated batching restrictions
Restored access to IDR for smaller claims
Congress intended the NSA to be a fair means of protecting patients from surprise bills. Tilting the scales in favor of insurers was unfair to physicians, providers, and the patients we care for.
Enforcement Crisis
A critical issue emerged in 2025 regarding whether IDR decisions are actually enforceable.
Circuit Split on Enforcement
Fifth Circuit (June 2025)
Ruled IDR awards NOT enforceable in federal court
Connecticut Court
Ruled the opposite: NSA makes IDR payments obligatory
Supreme Court declined to review, creating significant uncertainty for providers.
If the Fifth Circuit decision stands, Congress's scheme will be upended.
Insurer Countersuits
In a significant escalation, major insurers began filing their own lawsuits against provider groups in 2024 and 2025.
Recent Insurer Actions
Elevance & Aetna lawsuits
Suing provider groups over volume of "seemingly ineligible claims"
Fraud allegations
Insurers claiming 39% of disputes ineligible (vs. 17% actually found so)
Elevance 10% penalty policy
New controversial policy penalizing providers
They're really alleging a broad scheme of widespread fraud. It feels like a real escalation.
Future Outlook
The IDR landscape will continue evolving. Key developments to watch:
Near Term (2025 to 2026)
- • TMA III en banc decision (~1 year)
- • Resolution of enforcement circuit split
- • Potential Congressional action
- • Ground ambulance advisory committee report
Longer Term
- • Premium impact studies
- • PE scrutiny and potential regulation
- • IDR entity consistency standards
- • State law harmonization
Key Research & Voices
The experts shaping IDR policy and analysis
Brookings Institution
Loren Adler
Fellow & Associate Director, USC-Brookings Schaeffer Initiative
Member, Advisory Committee on Ground Ambulance and Patient Billing
Key Research Findings:
- • Median IDR decision is at least 3.7× what Medicare would pay
- • Emergency services IDR prices: 4.0× Medicare rates
- • Imaging services IDR prices: 6.6× Medicare rates
- • Four PE-backed companies generated 74% of line items in sample
Matthew Fiedler, PhD
Joseph A. Pechman Senior Fellow, Economic Studies
Co-author of influential regulatory comments on QPA methodology
Georgetown CHIR
Jack Hoadley, PhD
Research Professor Emeritus, Health Policy Institute
Former member, Medicare Payment Advisory Commission (MedPAC)
Key Research: "$5 Billion" Study
Landmark August 2025 analysis revealing the true costs of the IDR system, including additional provider payments, administrative costs, and system inefficiencies.
Kennah Watts
Research Fellow, Center on Health Insurance Reforms
IDR entity analysis, dispute volume tracking, PE provider patterns
USC Schaeffer Center
Erin Trish, PhD
Co-Director, USC Schaeffer Center; Nonresident Fellow, Brookings
Testified before U.S. House of Representatives and California State Assembly
Key Research Focus:
- • Surprise medical bills and state law variations
- • PE-backed provider behavior in IDR
- • Market concentration effects on healthcare pricing
Resources & Glossary
Reference materials and next steps
Key Terms & Definitions
Important Links
Federal IDR Portal
CMS
Georgetown CHIR Blog
Georgetown
Brookings Health Policy
Brookings
Health Affairs Forefront
Health Affairs
Peterson-KFF Tracker
KFF
TMA Litigation Tracker
Georgetown
Get Expert Help
Sources: Brookings Institution, Georgetown CHIR, USC Schaeffer Center, Health Affairs, KFF, Texas Medical Association, CMS, Fifth Circuit Court of Appeals
Last updated: January 2026
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