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 embody most emergency companies, non-emergency companies from OON suppliers at in-network amenities, and companies 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 occasion can request an impartial dispute decision (IDR), by which 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 companies launched public use information (PUFs) with information on the resolved IDR instances for 2023. In March 2025, the companies launched PUFs for the primary two quarters of 2024. These information embody data on the supplier and payer, in addition to provide quantities from every occasion––expressed as a share of a qualifying fee quantity (QPA), the inflation-adjusted median fee paid by a particular insurer in 2019 to its contracted in-network suppliers, primarily based on insurance coverage sort and geographic location. The information additionally embody data 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 traits 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 longer term 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.
Fast Charges Of New Case Filings; Extra Selections Rising From IDR Entities
The amount of filed IDR instances remained excessive. The six-month complete for filed instances (586,581) in Q1 and Q2 of 2024 is sort of as excessive as all of 2023 (657,040 filed instances), although this can be partly resulting from durations 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 greater in Q1 and Q2 of 2024 (45 p.c) than in all of 2023 (37 p.c), however the fee 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 willpower course of in sure states.
In 2024, the tempo of IDR entity decision-making accelerated considerably. About 335,000 fee determinations have been made in Q1 and Q2 of 2024, in comparison with about 200,000 instances in all of 2023. The amount 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 occasion submitted a proposal—a fee that has remained typically regular from 2023 to 2024. Discussions with stakeholders steered 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 have 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 have 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 the majority continuously 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 Group Well being.
Suppliers Proceed To See Extra Success Than Plans
Suppliers proceed to win way more usually and at a lot greater 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 gained 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 presents are a lot greater than plans. In Q1 of 2024, the median prevailing supplier provide was 383 p.c of QPA. This rose almost 70 share factors in Q2, with a median prevailing supplier provide of 447 p.c of QPA. Against this, the comparable charges in 2023 have 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.
Massive Supplier Teams Proceed To Prevail At Excessive Charges; Third-Social gathering Entities Emerge
As in 2023, resolved IDR instances have been predominantly from just a few giant supplier organizations – largely backed by personal fairness. Radiology Companions was essentially the most frequent person 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 almost 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 prime 5 supplier organizations gained the overwhelming majority of their disputes, with provide quantities at the least 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, Group Well being, SCP Well being, and AGS Well being remained comparatively steady 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 presents elevated considerably as properly: in Q1 of 2023, the group prevailed in 17 p.c of resolved instances, however their win fee steadily elevated to 84 p.c in This autumn of 2023. This success fee seems steady, 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 giant supplier organizations like Radiology Companions and Group Well being have the inner sources 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 acquainted with the IDR course of wrote in a earlier Forefront piece, “smaller practices have much less capability to entry IDR than do bigger, well-capitalized organizations.” This development could be altering with the rise of IDR-specific middlemen.
Emergency And Radiology Providers Account For Two-Thirds Of Resolved IDR Circumstances
The median prevailing presents 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 Supply 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 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 provide for emergency companies was 257 p.c of QPA, a greater than 30 share level enhance from 224 p.c in This autumn of 2023. Radiology companies skilled the same enhance in win quantities: within the first half of 2024, the median prevailing provide in radiology instances was 40 share 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 almost all of radiology instances, whereas Group Well being, SCP Well being, and Envision characterize properly over half of all emergency instances.
Neurology and surgical procedure, although a smaller quantity (about 9 p.c of resolved instances in 2024), gained a lot greater awards than radiology or emergency companies. In Q1 of 2024, the median prevailing occasion provide for neurology was 1222 p.c of QPA, adopted by 1178 p.c in Q2. The median prevailing occasion provide for surgical procedure was 1818 p.c of QPA in Q1 and 1716 p.c of QPA in Q2.
Plan Provides Minimally Improve; 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 p.c of resolved instances in Q1 to fifteen p.c in This autumn. Outcomes from 2024 are related: plans gained 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, enhance of 5 p.c from 2023. This shift may point out some effort by plans to reply to their historical past of dropping 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 occasion 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 p.c and seven p.c, respectively). The elevated quantity of instances attributable to administration firms could possibly 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 Selections
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 could resolve 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 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 may have a big influence 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 think about and weigh the related statutory components when deciding between two presents. However suppliers haven’t been profitable in instances throughout the board. The Biden Administration gained an attraction 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 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 Could 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 means 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 rapid 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. Numerous 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 immediately. The leads to such instances have been combined up to now, with appeals filed within the Fifth and Eleventh Circuits. The Division of Justice (DOJ), by means of amicus briefs, has urged courts to seek out that arbitration entities themselves should not correct events to such instances—arguing that such litigation finally may lead to “thwarting Congress’s want 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 instructed 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 means of 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 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 moderately 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 inexpensive fee for OON companies. 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 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 may shed some gentle on the contrasting claims round QPAs.
Findings from the IDR information increase two essential considerations. 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 may prolong entry to the IDR course of to suppliers who should not a part of giant organizations and thus face administrative burdens in utilizing the system. However, such organizations could contribute to greater total 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 presents are merely extra affordable 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 companies famous in background supplies: “Whereas well being plans and issuers usually benchmarked their presents to the QPA, suppliers, amenities, and air ambulance service suppliers usually benchmarked their presents 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 distinct plan or issuer in the identical state.” Plans have raised considerations that historic benchmarks could 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 shoppers. 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 instances, together with the prevalence of ineligible instances, could possibly be tempered if proposed guidelines for course of enhancements have 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 cut back among the uncertainties within the course of.
The longer-term influence of IDR selections on well being prices remains to be largely unknown. On the floor, it appears that evidently the excessive supplier profitable fee and the dimensions of the funds awarded would increase well being prices and plan premiums. However the magnitude of any such enhance 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 now have seen an influence of the NSA on the dimensions 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 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 inexpensive 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 shoppers specifically.
To be taught extra about variation within the IDR course of and potential value implications, learn the just lately printed companion piece: No Surprises Act Arbitrators Fluctuate 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 Challenge HOPE – The Folks-to-Folks Well being Basis, Inc.
