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 services from stability billing customers for a lot of facility-based OON medical providers. Companies topic to the legislation embody most emergency providers, non-emergency providers from OON suppliers at in-network services, and providers from OON air ambulance suppliers.
Below the legislation, 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 unbiased dispute decision (IDR), through 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 information on the resolved IDR circumstances 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 celebration––expressed as a share of a qualifying fee quantity (QPA), the inflation-adjusted median price paid by a selected insurer in 2019 to its contracted in-network suppliers, based mostly on insurance coverage kind 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 developments within the IDR course of throughout supplier and payer varieties, supply quantities, geographic places, 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 amount of filed IDR circumstances remained excessive. The six-month whole for filed circumstances (586,581) in Q1 and Q2 of 2024 is sort of as excessive as all of 2023 (657,040 filed circumstances), although this can be partly attributable to 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 circumstances challenged as ineligible was larger in Q1 and Q2 of 2024 (45 p.c) than in all of 2023 (37 p.c), however the price of closed circumstances later discovered ineligible was considerably decrease: about 18 p.c in 2024 versus 22 p.c 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 circumstances in all of 2023. The amount within the second quarter of 2024 was additionally nicely above that within the first quarter. Notably, about one in six determinations are made in circumstances the place just one celebration submitted a suggestion—a price that has remained typically regular from 2023 to 2024. Discussions with stakeholders steered that this consequence 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 circumstances 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 circumstances 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 steadily used IDR. For instance, throughout most quarters, greater than half of the circumstances in Texas concerned Radiology Companions affiliated suppliers. Equally, two-thirds of Tennessee and Florida circumstances concerned Group Well being.
Suppliers Proceed To See Extra Success Than Plans
Suppliers proceed to win much more typically and at a lot larger supply quantities than plans. In 2023, the speed of suppliers prevailing rose from 70 p.c of resolved circumstances in Q1 to 87 p.c in This autumn. Charges in 2024 matched the latter ranges: suppliers gained 88 p.c and 83 p.c of resolved circumstances in Q1 and Q2, respectively (Exhibit 2).
Exhibit 2. % 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 much more typically, however their prevailing gives are a lot larger than plans. In Q1 of 2024, the median prevailing supplier supply was 383 p.c of QPA. This rose practically 70 share factors in Q2, with a median prevailing supplier supply of 447 p.c of QPA. Against this, the comparable charges in 2023 had been between 320 p.c and 350 p.c. In circumstances the place plans prevailed, their median supply quantity was a lot decrease: 105 p.c of QPA in each Q1 and Q2 of 2024.
Massive Supplier Teams Proceed To Prevail At Excessive Charges; Third-Occasion Entities Emerge
As in 2023, resolved IDR circumstances 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 Group Well being, SCP Well being, AGS Well being, and HaloMD. Mixed, these 5 organizations account for practically two-thirds (63 p.c) of resolved circumstances (Exhibit 3).
Exhibit 3. Share of Resolved IDR Instances by Prime Supplier Organizations, Q1-Q2 2024
Supply: Authors’ evaluation of Federal IDR PUFs, Reporting Yr 2024.
Along with a excessive quantity of circumstances, these high 5 supplier organizations gained 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 p.c of QPA and 610 p.c of QPA within the first half of 2024.
Whereas the exercise degree of Radiology Companions, Group 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 circumstances. 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 nicely: in Q1 of 2023, the group prevailed in 17 p.c of resolved circumstances, however their win price steadily elevated to 84 p.c in This autumn of 2023. This success price 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 providers.” HaloMD illustrates the rise of revenue enhancing middlemen targeted on the IDR course of. Whereas massive supplier organizations like Radiology Companions and Group Well being have the inner assets 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 have interaction 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 pattern is likely to 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 % 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 circumstances, 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 p.c of QPA, a greater than 30 share level enhance from 224 p.c in This autumn of 2023. Radiology providers skilled an analogous enhance in win quantities: within the first half of 2024, the median prevailing supply in radiology circumstances was 40 share factors greater than the top 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 circumstances, whereas Group Well being, SCP Well being, and Envision characterize nicely over half of all emergency circumstances.
Neurology and surgical procedure, although a smaller quantity (about 9 p.c of resolved circumstances in 2024), gained a lot larger awards than radiology or emergency providers. In Q1 of 2024, the median prevailing celebration supply for neurology was 1222 p.c of QPA, adopted by 1178 p.c in Q2. The median prevailing celebration supply for surgical procedure was 1818 p.c of QPA in Q1 and 1716 p.c of QPA in Q2.
Plan Presents Minimally Improve; 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 circumstances in Q1 to fifteen p.c in This autumn. Outcomes from 2024 are related: plans gained 14 p.c of resolved circumstances in Q1 and 18 p.c in Q2. As beforehand acknowledged, in circumstances the place plans prevailed, the median prevailing supply quantity was 105 p.c in each quarters of 2024—a small, however not insignificant, enhance of 5 p.c from 2023. This shift might point out some effort by plans to reply to their historical past of dropping IDR circumstances.
In Q1 and Q2 of 2024, the majority of resolved IDR circumstances concerned a number of massive plans as recipients of circumstances filed by suppliers. United Healthcare, Aetna, HCSC, and Anthem accounted for 2 thirds of circumstances. By one nationwide measure, these 4 firms account for practically half of the nationwide insurer market.
Third celebration claims administration firms account for at the least a fifth of resolved circumstances. 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 circumstances attributable to administration firms might be proof that plans, like suppliers, additionally leverage intermediaries to handle their disputes and maximize their OON claims income.
Vital 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 likely be diminished. 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 information. We discover that 4 IDR entities made selections favoring suppliers in over 90 p.c of their circumstances in 2024, whereas one entity favored suppliers in solely one-third of its circumstances. Ideally, the general decision-making sample must be related throughout all IDREs, so it is going to 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 circumstances and appeals might have a major affect on the success of the arbitration course of and its position 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 contemplate and weigh the related statutory elements when deciding between two gives. However suppliers haven’t been profitable in circumstances throughout the board. The Biden Administration gained an attraction earlier than a Fifth Circuit panel final fall in an extra 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 courtroom’s choice 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 Could 30, 2025, the fifth Circuit issued an order vacating the earlier opinion and directing that the case be reheard en banc (by all energetic judges on the courtroom). 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 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 underneath the Administrative Process Act and the Takings Clause of the Fifth Modification. Numerous different ongoing circumstances relate to efforts to overturn sure arbitration awards or compel fee by a celebration to arbitration. Some contain circumstances introduced by suppliers towards insurers and arbitration entities immediately. The leads to such circumstances have been blended to date, 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 should not correct events to such circumstances—arguing that such litigation in the end might lead to “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 reduction in courts for such nonpayment, “one of many [NSA]’s core options can 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 circumstances with a purpose to acquire improper fee charges. Such circumstances stay within the early phases, 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 circumstances exhibits that suppliers are sometimes turning to IDR somewhat than accepting preliminary plan funds. Though nearly all of circumstances are deemed eligible for the IDR course of, plans are difficult the eligibility of practically half the circumstances 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 doable manipulation of the QPA. Plans reply that their QPAs are correct and that suppliers must be keen to simply 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 information increase two essential issues. First, IDR circumstances 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 might lengthen entry to the IDR course of to suppliers who should not a part of massive organizations and thus face administrative burdens in utilizing the system. Then again, such organizations might contribute to larger general case quantity, growing prices for the entire well being system.
Moreover, suppliers proceed to have a excessive share of circumstances determined of their favor, leading to massive fee awards. Suppliers make the case that their gives are merely extra affordable and that arbitrators agree. There are additionally some anecdotal stories 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 typically benchmarked their gives to the QPA, suppliers, services, and air ambulance service suppliers typically 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 issues that historic benchmarks might replicate circumstances earlier than passage of the NSA when some plans paid full billed fees to make sure that prices weren’t handed alongside to customers. With out public reporting of the rationale for IDR entity selections, observers can solely speculate how a lot historic funds affect the choices.
The excessive quantity of IDR circumstances, together with the prevalence of ineligible circumstances, might 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 among the uncertainties within the course of.
The longer-term affect of IDR selections on well being prices continues to be largely unknown. On the floor, it appears that evidently the excessive supplier successful price and the scale of the funds awarded would increase well being prices and plan premiums. However the magnitude of any such enhance is proscribed by the share of all well being care claims represented by the IDR circumstances. Moreover, stakeholder claims diverge wildly on whether or not we’ve 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 concerning the effectiveness of the NSA in stopping customers from experiencing shock payments within the situations the place the NSA created protections. The problem stays whether or not the legislation’s mechanism for establishing an affordable fee from plans to suppliers is working. To the extent it isn’t, a key query is whether or not there are price implications for the well being care system as a complete and for customers particularly.
To study extra about variation within the IDR course of and potential price implications, learn the just lately revealed companion piece: No Surprises Act Arbitrators Range Considerably In Their Resolution 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 Venture HOPE – The Individuals-to-Individuals Well being Basis, Inc.
