By Jack Hoadley, Kennah Watts, and Zachary Baron
The No Surprises Act (NSA) protects shoppers from shock out-of-network (OON) billing by banning suppliers and amenities from stability billing shoppers for a lot of facility-based OON medical companies. Providers topic to the regulation embrace most emergency companies, non-emergency companies from OON suppliers at in-network amenities, and companies from OON air ambulance suppliers.
Beneath 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 celebration can request an impartial dispute decision (IDR), wherein a third-party arbitrator (“IDR entity”) binds each events to both the plan or supplier provide.
In 2024, in compliance with NSA necessities, the related federal businesses launched public use information (PUFs) with knowledge on the resolved IDR instances for 2023. In March 2025, the businesses launched PUFs for the primary two quarters of 2024. These information embrace info on the supplier and payer, in addition to provide quantities from every celebration––expressed as a proportion of a qualifying fee quantity (QPA), the inflation-adjusted median charge paid by a selected insurer in 2019 to its contracted in-network suppliers, primarily based on insurance coverage sort and geographic location. The information additionally embrace info on the prevailing provide, 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 developments within the IDR course of throughout supplier and payer varieties, provide 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 businesses’ supplemental tables, from our personal evaluation of the PUFs, and from discussions with stakeholders.
Speedy Charges Of New Case Filings; Extra Selections 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 intervals in 2023 when the IDR portal was suspended.
Exhibit 1. Variety of Filed IDR Circumstances 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 increased in Q1 and Q2 of 2024 (45 p.c) than in all of 2023 (37 p.c), however the charge of closed instances later discovered ineligible was considerably decrease: about 18 p.c in 2024 versus 22 p.c in 2023. Circumstances could also be ineligible primarily based on the dates of service, whether or not a case is roofed by the NSA, or the necessity to undergo a state fee dedication 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 effectively above that within the first quarter. Notably, about one in six determinations are made in instances the place just one celebration submitted a suggestion—a charge that has remained usually regular from 2023 to 2024. Discussions with stakeholders recommended that this end result could also be the results of plans being overwhelmed by case quantity and unable to reply earlier than deadlines.
Circumstances Stay Concentrated In A Few States
IDR use remained extremely concentrated by geography. States with excessive volumes of resolved instances had been usually the identical as in 2023: Texas, Florida, Arizona, Tennessee, Georgia, New Jersey, and New York. In contrast, 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 p.c and 91 p.c 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 incessantly 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 Staff Well being.
Suppliers Proceed To See Extra Success Than Plans
Suppliers proceed to win way more usually and at a lot increased provide quantities than plans. In 2023, the speed of suppliers prevailing rose from 70 p.c of resolved instances in Q1 to 87 p.c in This autumn. Charges in 2024 matched the latter ranges: suppliers received 88 p.c and 83 p.c of resolved instances in Q1 and Q2, respectively (Exhibit 2).
Exhibit 2. % of Resolved IDR Circumstances Received by Suppliers, Q1-This autumn 2023 and Q1-Q2 2024
Supply: Authors’ evaluation of Federal IDR PUFs, Reporting 12 months 2023 and 2024.
Not solely do suppliers win way more usually, however their prevailing gives are a lot increased than plans. In Q1 of 2024, the median prevailing supplier provide was 383 p.c of QPA. This rose practically 70 proportion factors in Q2, with a median prevailing supplier provide of 447 p.c of QPA. In contrast, the comparable charges in 2023 had been between 320 p.c and 350 p.c. In instances the place plans prevailed, their median provide quantity was a lot decrease: 105 p.c of QPA in each Q1 and Q2 of 2024.
Giant Supplier Teams Proceed To Prevail At Excessive Charges; Third-Occasion Entities Emerge
As in 2023, resolved IDR instances had been predominantly from a number of massive supplier organizations – largely backed by personal fairness. Radiology Companions was probably the most frequent consumer of IDR in Q1 and Q2 of 2024, adopted by Staff Well being, SCP Well being, AGS Well being, and HaloMD. Mixed, these 5 organizations account for practically two-thirds (63 p.c) of resolved instances (Exhibit 3).
Exhibit 3. Share of Resolved IDR Circumstances by Prime Supplier Organizations, Q1-Q2 2024
Supply: Authors’ evaluation of Federal IDR PUFs, Reporting 12 months 2024.
Along with a excessive quantity of instances, these high 5 supplier organizations received the overwhelming majority of their disputes, with provide quantities no less than two instances better than QPA. Radiology Companions considerably outmatched different supplier teams, with a median prevailing provide at 631 p.c of QPA and 610 p.c of QPA within the first half of 2024.
Whereas the exercise stage of Radiology Companions, Staff 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 only one p.c of resolved disputes, whereas in Q2 of 2024, HaloMD initiated 10 p.c of disputes. HaloMD’s prevailing gives elevated considerably as effectively: in Q1 of 2023, the group prevailed in 17 p.c of resolved instances, however their win charge steadily elevated to 84 p.c in This autumn of 2023. This success charge seems secure, reaching 89 p.c and 81 p.c in Q1 and Q2 of 2024.
HaloMD was particularly created “to be the main supplier of IDR companies.” HaloMD illustrates the rise of revenue enhancing middlemen centered on the IDR course of. Whereas massive supplier organizations like Radiology Companions and Staff Well being have the interior assets to handle disputes on behalf of their suppliers, HaloMD and different third-party organizations can tackle the executive burden for smaller suppliers and provide them a better alternative to have interaction in IDR. As a supplier group conversant in the IDR course of wrote in a earlier Forefront piece, “smaller practices have much less means to entry IDR than do bigger, well-capitalized organizations.” This pattern is likely to be altering with the rise of IDR-specific middlemen.
Emergency And Radiology Providers Account For Two-Thirds Of Resolved IDR Circumstances
The median prevailing gives relative to QPA in Q1 and Q2 of 2024, by supplier specialty, usually match or exceed these in 2023 (Exhibit 4). For many specialties, the median proportion of QPA grew throughout the 4 quarters of 2023.
Exhibit 4. Median Prevailing Provide amongst Resolved IDR Circumstances as % of QPA by Specialty, Q1-This autumn 2023 and Q1-Q2 2024
Supply: Authors’ evaluation of Federal IDR PUFs, Reporting 12 months 2023 and 2024.
Radiology and emergency companies are the 2 specialties with the best quantity of resolved instances, accounting for about two-thirds of all determinations (not proven). Within the first half of 2024, the median prevailing provide for emergency companies was 257 p.c of QPA, a greater than 30 proportion level improve from 224 p.c in This autumn of 2023. Radiology companies skilled the same improve in win quantities: within the first half of 2024, the median prevailing provide in radiology instances was 40 proportion factors greater than the tip of 2023 (600 p.c QPA and 559 p.c QPA, respectively). These specialties are carefully correlated to sure supplier teams. For instance, Radiology Companions accounts for practically all of radiology instances, whereas Staff Well being, SCP Well being, and Envision characterize effectively over half of all emergency instances.
Neurology and surgical procedure, although a smaller quantity (about 9 p.c of resolved instances in 2024), received a lot increased awards than radiology or emergency companies. In Q1 of 2024, the median prevailing celebration provide for neurology was 1222 p.c of QPA, adopted by 1178 p.c in Q2. The median prevailing celebration provide for surgical procedure was 1818 p.c of QPA in Q1 and 1716 p.c of QPA in Q2.
Plan Affords Minimally Enhance; Win Charges Stay Low
Plan success in IDR is usually related throughout 2023 and 2024. In 2023, the speed of plans prevailed declined from 28 p.c of resolved instances in Q1 to fifteen p.c in This autumn. Outcomes from 2024 are related: plans received 14 p.c of resolved instances in Q1 and 18 p.c in Q2. As beforehand acknowledged, in instances the place plans prevailed, the median prevailing provide quantity was 105 p.c in each quarters of 2024—a small, however not insignificant, improve of 5 p.c from 2023. This shift might point out some effort by plans to reply to their historical past of shedding IDR instances.
In Q1 and Q2 of 2024, the majority of resolved IDR instances concerned a number of massive 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 corporations account for practically half of the nationwide insurer market.
Third celebration claims administration corporations account for no less than a fifth of resolved instances. MultiPlan (now Claritev) and Clear Well being Methods are the 2 largest entities (13 p.c and seven p.c, respectively). The elevated quantity of instances attributable to administration corporations may very well 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 Selections
The tempo of IDR entity decision-making has considerably accelerated in 2024, yielding hope that case backlogs can be diminished. However our conversations with stakeholders have indicated one other potential concern: that some IDR entities could 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 p.c 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 it is going to be essential to grasp 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 might have a big influence 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 attraction earlier than a Fifth Circuit panel final fall in an additional problem introduced by the Texas Medical Affiliation and air ambulance suppliers (typically 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 court docket’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 court docket). Briefing will run by way of 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 speedy influence of this improvement on sufferers and the arbitration course of.
In one other case on pause in federal district court docket in Kentucky, suppliers challenged a number of NSA regulatory provisions beneath 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 towards insurers and arbitration entities instantly. The ends in such instances have been blended to this point, with appeals filed within the Fifth and Eleventh Circuits. The Division of Justice (DOJ), by way of amicus briefs, has urged courts to search out that arbitration entities themselves will not be correct events to such instances—arguing that such litigation in the end might 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 informed courts that if events can’t acquire reduction in courts for such nonpayment, “one of many [NSA]’s core options could be pissed off, upending Congress’s scheme.”
Insurers have additionally filed a number of lawsuits alleging supplier abuse of the IDR course of by way of submitting ineligible instances in an effort to acquire improper fee charges. Such instances stay within the early levels, but when they proceed, discovery might shed extra gentle 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 slightly 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 practically 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 companies. Suppliers imagine 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 keen 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 might shed some gentle on the contrasting claims round QPAs.
Findings from the IDR knowledge increase two essential issues. First, IDR instances are considerably concentrated amongst just some supplier organizations. Second, middlemen organizations are more and more frequent customers of the system. On one hand, intermediary organizations might prolong entry to the IDR course of to suppliers who will not be a part of massive organizations and thus face administrative burdens in utilizing the system. However, such organizations could contribute to increased 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 massive fee awards. Suppliers make the case that their gives are merely extra cheap and that arbitrators agree. There are additionally some anecdotal experiences that plans have been much less aggressive than suppliers in placing their arguments in entrance of the IDR entities. Because the federal businesses 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 special plan or issuer in the identical state.” Plans have raised issues that historic benchmarks could replicate circumstances earlier than passage of the NSA when some plans paid full billed expenses to make sure that prices weren’t handed alongside to shoppers. With out public reporting of the rationale for IDR entity choices, observers can solely speculate how a lot historic funds affect the selections.
The excessive quantity of IDR instances, together with the prevalence of ineligible instances, may very well be tempered if proposed guidelines for course of enhancements had been finalized and if ongoing litigation over the QPA methodology was resolved. Higher schooling, coaching, and oversight of IDR entity decision-making may also assist scale back a number of the uncertainties within the course of.
The longer-term influence of IDR choices on well being prices remains to be largely unknown. On the floor, evidently the excessive supplier successful charge and the scale of the funds awarded would increase well being prices and plan premiums. However the magnitude of any such improve is restricted by the share of all well being care claims represented by the IDR instances. Moreover, stakeholder claims diverge wildly on whether or not we have now seen an influence 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 shoppers 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 price implications for the well being care system as a complete and for shoppers particularly.
To be taught extra about variation within the IDR course of and potential price implications, learn the not too long ago revealed companion piece: No Surprises Act Arbitrators Range Considerably In Their Determination Making Patterns.
Jack Hoadley, Kennah Watts, and Zachary Baron “Unbiased 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 Challenge HOPE – The Individuals-to-Individuals Well being Basis, Inc.
