Why It Matters
Deep structural problems plague the federal dispute resolution system designed to protect patients from shock medical bills, according to a Congressional Research Service (CRS) report on the No Surprises Act (NSA).
The NSA, enacted as part of the Consolidated Appropriations Act of 2021, establishes federal consumer protections related to surprise billing when individuals receive large, unexpected medical bills from out-of-network providers. At its core sits an Independent Dispute Resolution (IDR) process before a private arbitrator to determine how much insurers must pay out-of-network providers for care. From 2023 through 2025, 4.7 million or more IDR disputes were initiated, with 85.7% resulting in the out-of-network provider or facility as the prevailing party.
The Big Picture
If no agreement is reached during open negotiation, either party may proceed to the IDR process starting at Day 110. The non-initiating party responds by Day 116, preliminary joint selection or random assignment of an IDR entity occurs by Day 121, and the IDR entity determines dispute eligibility by Day 124. Final IDR entity selection and parties pay administrative fees to the Centers for Medicare & Medicaid Services (CMS) by Day 129. Each party submits a payment offer by Day 137, the IDR entity selects between offers by Day 144, and the relevant party must pay or reimburse amounts per determination by Day 172. The IDR entity refunds the IDR entity fee to the prevailing party by Day 202, and the process concludes by Day 214.
The IDR process was launched in April 2022 but was not fully operational without suspension until 2024, meaning it took roughly two years from its launch to function continuously. The IDR system was flooded with claims far beyond initial projections, creating a massive backlog of unresolved disputes.
Providers have aggressively contested the Qualifying Payment Amount (QPA), which is generally an insurer's 2019 median in-network rate for the item or service, indexed for inflation. Providers argue insurers artificially suppress the metric to tilt arbitration in their favor. Research has shown that some prices actually rose after arbitration, contrary to legislative expectations. Meanwhile, some physician practices report that health plans used the No Surprises Act framework to justify cutting or terminating in-network contracts.
On June 4, 2026, federal agencies, the Department of Health and Human Services, the Department of Labor and Treasury, finalized a sweeping IDR Operations rule. The rule reduced the administrative fee from $115 to $15 per party per dispute, established a 50-line batching cap limiting how many line items can be bundled into one dispute, and requires payors to disclose the QPA and contact information for open negotiation. The June 2026 IDR Operations rule became effective on June 11. Yet even these adjustments may not resolve the underlying tension: the Trump administration has extended enforcement discretion on QPA calculation methods, meaning insurers have continued using older calculation methodologies beyond their originally intended expiration.
The Bottom Line
The IDR entity's selection is generally not judicially reviewable. Because patient cost-sharing is tied to the QPA, any regulatory or legal change that raises the QPA directly increases patient out-of-pocket costs for out-of-network care.
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