The No Surprises Act was made to protect patients from unexpected charges when they get care from out-of-network providers without knowing, especially in emergencies or some non-emergency treatments in in-network facilities.
The NSA says that if health plans and providers cannot agree on a payment after trying to talk it over, they go into the IDR process.
IDR is a binding arbitration system run by federal departments like the Department of Health and Human Services (HHS), the Department of Labor, and the Department of the Treasury.
After a 30-business-day negotiation period, either side can start the IDR process within four business days by picking a certified neutral third party to review the payment offers and decide which amount is accepted.
The process needs detailed claims info such as service dates, place, codes, and Explanation of Benefits (EOB). It also makes sure there are no conflicts of interest between the parties and the IDR entities.
Since the Federal IDR portal opened in April 2022, the number of disputes has increased a lot.
By November 2025, more than 4.6 million disputes were started, and about 4.28 million were finished. Still, there is a big backlog to clear.
This many disputes put pressure on administrative staff and slow down payment resolutions.
Provider groups backed by private equity have caused much of this rise.
In data from early 2024, 90% of IDR disputes were started by providers and facilities.
Providers won about 80% of the payment decisions.
They often got paid well above median in-network rates—sometimes more than three times the qualifying payment amount (QPA), or even ten times in some fields like neurology.
Because of this, many providers stay out-of-network instead of joining payer networks, which pushes up costs for insurers and may raise prices for consumers.
Just a few big provider groups filed most disputes.
Four private equity-backed companies filed about two-thirds of IDR cases in mid-2023.
This concentration makes it harder for practice administrators to handle billing disputes and plan payment timing under the arbitration rules.
Meanwhile, payers started less than 1% of disputes, showing an imbalance in how disputes happen and get settled.
The law says IDR decisions should be done within 30 calendar days of getting the case.
However, in reality, it often takes longer.
The median time to resolve disputes grew to 76 days in early 2023, more than twice the legal limit.
These delays hurt cash flow for medical practices and make financial planning harder.
Backlogs with hundreds of thousands of unresolved cases increased costs for both providers and payers because of the extra staff and resources needed to track disputes and submit documents.
Many disputes close for reasons not related to payment, like withdrawals, deals made outside IDR, or not following rules.
Some disputes are also ruled ineligible, so billing teams need to review carefully to avoid unneeded filings.
Besides providers and insurers, middlemen like Revenue Cycle Management (RCM) companies, claims denial companies, and repricing firms play a big part in IDR and out-of-network billing.
The U.S. RCM market was worth $155.6 billion in 2023 and is expected to grow as more providers hire these firms to handle billing and claims.
RCM companies help collect payments but may also promote practices like upcoding—coding services at higher payment levels than deserved.
This raises costs for insurers and patients.
Denial rates for claims vary a lot among insurers, with some denying almost half their claims, especially in commercial insurance.
AI-based denial systems might carry biases and miss clinical details, making claim results worse for providers.
Repricing companies work with insurers and keep 30 to 45 percent of the money saved from out-of-network payments.
Sometimes their fees are as high as or higher than what the providers get paid.
This network of middlemen adds more administrative work and makes it hard for managers to follow payment flows and predict reimbursements.
The problems with the IDR process have led federal agencies to propose rules to improve communication, reduce backlogs, and speed up resolutions.
Important ideas for making things better include:
Medical practice administrators face the hard job of handling IDR disputes.
They must track dispute status, gather documents, respond to requests, and deal with payment delays.
This takes extra labor and hurts practice income.
IT managers can help by using workflow automation and data integration to support IDR tasks.
This can include checking codes, sending documents automatically to IDR entities, tracking deadlines, and alerting staff.
Centralizing these steps reduces mistakes and speeds up case handling, which leads to faster payments and better financial health for practices.
Practice leaders need to keep up with rules and procedures for the IDR process.
They should work closely with billing companies or in-house RCM teams to spot disputes early and handle them properly.
Training staff on document and submission rules is key to avoiding ineligible cases or delays.
The IDR process is complex. It needs many documents, has tight deadlines, and requires a lot of back-and-forth communication.
Technology like automation and AI can help improve this.
Automated Claim Submission and Document Management:
AI systems can read claims data, check eligibility, and gather needed proof like EOBs and service records for IDR submissions.
Automation lowers manual work, prevents human mistakes, and speeds up filing.
Deadline Monitoring and Alert Systems:
Automation tools can watch the 30-business-day negotiation period and the 4-business-day IDR filing window.
Alerts make sure no deadlines are missed, protecting provider rights and helping timely filings.
Predictive Analytics for Dispute Outcomes:
AI can look at past arbitration results to guess chances of winning disputes based on claim details.
This helps providers focus on cases with better odds, using resources wisely.
Communication Bots and Support Interfaces:
AI chatbots or assistants can answer routine billing questions or check status with IDR entities.
This reduces work for staff and improves response times.
Data Security and Compliance:
Automation must follow HIPAA rules and use encryption and access controls to protect healthcare billing data.
Secure cloud systems help work with third-party IDR groups while keeping data safe.
IT managers should consider healthcare automation software made for IDR workflows.
It can save money by lowering overhead, speeding dispute resolution, and improving cash flow.
As disputes grow, such technology will be more important.
Although the NSA protects patients from surprise bills, the way the IDR system works now may increase costs indirectly.
Providers often win cases and get payments much higher than median in-network rates.
This raises costs for insurers and may push premiums higher.
It also limits network size.
States like Tennessee, Texas, and Arizona have higher rates of IDR disputes per person.
This matches areas where big private equity-backed provider groups work.
High provider success rates discourage joining networks, keeping an out-of-network approach that relies on arbitration instead of agreements.
Hospital and practice leaders need careful financial planning and billing management.
Knowing local IDR trends and laws helps make better choices about network participation and pricing.
Through thoughtful reforms, stronger federal oversight, and more use of AI-driven automation, the IDR process can become clearer, faster, and easier to manage.
These changes are important for medical practice administrators, owners, and IT teams trying to cut extra work, lower payment delays, and follow rules.
As the system changes, working together among providers, payers, regulators, and technology experts will be key to making a fair and lasting way to resolve out-of-network claims in the United States.
The No Surprises Act aims to prevent surprise billing for patients treated by out-of-network providers in emergencies or without prior knowledge, ensuring consumers do not receive unexpected high charges for care.
Under the IDR process, if payers and providers cannot agree on payment, each presents an offer, and an arbitrator selects one of them as binding. The process emphasizes a qualifying payment amount (QPA), representing the median in-network rate for services.
Providers won approximately 77% of resolved IDR cases, often receiving significantly higher payments — about 322% of the QPA when they won, compared to 100% when payers were successful.
The current trend of providers winning the majority of IDR cases and receiving high compensation may lead to increased healthcare costs, potentially undermining the NSA’s goal of cost containment.
In the first half of 2023, approximately 288,000 new IDR cases were filed, far exceeding earlier estimates and resulting in significant backlogs in resolution.
A few provider organizations, mostly backed by private equity, accounted for a large share of IDR filings, often leveraging surprise billing as a previous business strategy aimed at maximizing revenues.
Most claims do not enter the IDR process; approximately 80% of out-of-network claims accepted initial payments from payers, while fewer than 7% progressed to IDR.
While the statutory requirement for IDR case resolution is 30 days, the median time reported in the first half of 2023 was 76 days, indicating significant delays.
Federal agencies proposed rule changes in October 2023 aimed at improving communication among stakeholders and expediting case submissions to address high volumes and delays.
The outcomes of litigation surrounding the IDR process and how stakeholders adapt may be crucial in determining whether the NSA can effectively meet its cost-containment objectives.
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