Why Are Health Plans Losing 88% of No Surprises Act Disputes?

The No Surprises Act's Independent Dispute Resolution (IDR) process, designed to keep patients out of billing disputes, has instead become an escalating battleground between providers and health insurers — with real cost consequences for health plans and their members.

What the IDR Process Was Meant to Do

The No Surprises Act, enacted as part of the Consolidated Appropriations Act of 2021. The law prohibits providers from billing patients more than in-network cost-sharing rates for out-of-network services in emergency and certain non-emergency situations. When a provider and health plan cannot agree on payment after a 30-day open negotiation period, either side can trigger the federal IDR process — a "baseball-style" arbitration where both parties submit their best offer and a certified third-party arbiter picks one. Federal regulators initially projected about 17,000 IDR cases per year.

The Volume Has Exploded

The actual volume has wildly exceeded projections. Nearly 2.3 million disputes were filed from January through November 2025 alone, and total disputes since April 2022 have exceeded 4.6 million. In just the first half of 2025, almost 1.2 million cases were submitted — up nearly 40% from the last six months of 2024 — while arbiters processed over 1.3 million disputes in that same period, up nearly 50%, working to cut into the existing backlog.

Providers Are Winning — Heavily

Providers prevailed in approximately 88% of disputes in the first half of 2025, up from 85% in the second half of 2024. When they win, the median award runs 2x to 4x the Qualifying Payment Amount (QPA) — the median in-network contracted rate for the same service and geography that insurers use as their benchmark offer. Over a span of 2.5 years through 2024, providers collectively reaped more than $2.2 billion through the arbitration process.

The "Gaming" Accusations

Both sides have accused the other of exploiting the system:

• Provider side: A small number of private equity-backed physician groups drive the bulk of cases. The top three initiating parties — IDR middleman HaloMD, and PE-backed providers TeamHealth and SCP Health — accounted for roughly 44% of all disputes filed in the first half of 2025. Georgetown University researchers found just two PE-backed groups (Radiology Partners and TeamHealth) were responsible for 43% of all resolved line-item claims. Payer groups and employer coalitions argue these organizations are using IDR as a deliberate revenue strategy, flooding the system with bulk filings — including ineligible claims — to pressure insurers into settling at inflated rates.
• Insurer side: About 20% of disputes submitted in the first half of 2025 were actually ineligible for the IDR process. Separately, some insurers have defaulted by not submitting offers or paying required fees, which leads arbiters to award providers by default — in some cases at amounts averaging nine times the original claim. Providers cite this as evidence that insurers are submitting artificially low payment offers when they do participate.

Patients Are Getting Caught in the Middle

Despite being the law's intended beneficiaries, patients are not fully shielded. Some billing disputes draw patients back into the process when providers bill patients directly for amounts that should be covered by the IDR outcome, or when ineligible claims slip through. Georgetown University's Center on Health Insurance Reforms estimates the IDR process has generated at least $5 billion in total administrative costs from 2022 to 2024 — costs that ultimately flow back into premiums.

What's New in 2026

Regulators are still working to finalize an IDR rule that would clarify eligibility determinations and accelerate the arbitration timeline. The Office of Management and Budget has held meetings with both insurer and provider representatives as it reviews the pending rule. The 5th Circuit Court of Appeals also previously struck down parts of the IDR regulations that were seen as favoring insurers by over-weighting the QPA, forcing the agencies to re-examine how arbiters are instructed to weigh evidence. Congressional reform proposals have called for benchmarking payments to median in-network rates and screening ineligible claims before they enter arbitration.

Why This Matters for Health Plans

For payers, the IDR situation creates several compounding pressures:

• Financial exposure: With providers winning 88% of cases at 2x–4x QPA, each unresolved dispute carries significant dollar risk.​
• Administrative burden: Managing IDR submissions, deadlines, and eligibility reviews requires dedicated resources — and failing to respond to a case can result in a default award nine times the original claim.​
• Data accuracy: Correctly tracking which providers are in-network, which claims are IDR-eligible, and what the applicable QPA is for a given service and geography requires accurate, up-to-date provider and contract data. Gaps in that data lead directly to financial losses in arbitration.
• Network strategy: Plans in high-dispute states like Texas, Florida, New Jersey, and New York face disproportionate volume, and some are using IDR outcome data to redesign plan networks and steer members away from high-dispute provider groups.​

Where Clean Data Becomes a Competitive Advantage

The IDR explosion is, at its core, a data problem. Every disputed claim that results in a costly arbitration award — or a costly default — traces back to a gap in what your organization knows about its providers: Is this provider actually in-network for this plan and geography? What is the applicable QPA for this service? Is this claim even IDR-eligible? When provider data lives across disconnected credentialing, contracting, and claims systems, those questions are harder to answer than they should be. The Gaine Health Data Management Platform (Gaine HDMP) addresses this directly.

Gaine HDMP consolidates provider data from across your enterprise into a single, continuously validated source of truth — pulling from authoritative sources like NPPES, DEA, OIG, and state licensing feeds — so your network participation status, contract terms, and eligibility determinations reflect current reality, not data that has degraded over the past quarter.

Built-in audit trails track every data change, with full source citations and timestamps, so your teams can reconstruct the state of a provider record at any point in time — exactly what you need to defend or dispute an IDR determination. And because Gaine HDMP integrates directly with downstream claims and directory systems, the same accurate data that keeps your directories compliant with No Surprises Act requirements also flows to the systems adjudicating the claims at the center of these disputes.

In a process where 20% of submitted cases are already ineligible, and where a single missed deadline can result in a default award nine times the original claim, the cost of not knowing your provider data is no longer theoretical.