Why is the IDR process receiving increased scrutiny?
Policymakers are increasingly scrutinizing the independent dispute resolution process because evidence suggests it is contributing to higher spending that increases health insurance costs for employers and families. Also, the volume of cases has surged far beyond what lawmakers expected when they created it.
- Higher costs are undermining affordability. A Health Affairs analysis estimates the IDR process generated $22.4 billion in excess costs from 2022 through 2025. Federal data shows that nearly $15 billion was awarded to healthcare providers in 2025 alone, up from $4.08 billion in 2024. Those costs ripple throughout the healthcare system, raising premiums and out-of-pocket costs for everyone.
- Large provider payouts contribute to higher premiums. Some health insurance providers have said that the increasing number of high provider payouts associated with IDR decisions is leading to an increase in premiums for employers and individuals. Plans covering state workers have also cited the process as a factor in rising insurance prices.
- The entities that decide the cases may collect fees up to $800 per case, creating financial incentives to hear more disputes, driving the volume that far exceeded policymakers’ projections.
- A small number of organizations are driving the majority of disputes. Just five middlemen and private equity-backed providers accounted for more than 60% of resolved IDR cases in 2024.
- The federal IDR process is being overwhelmed by disputes that don't qualify. Nearly 40% of disputes filed in 2024 were ineligible, yet roughly half still resulted in mandatory payments to providers.
- Dispute volumes far exceed expectations. Federal regulators originally projected about 17,000 disputes annually. Within months, the actual volume exceeded 10 times that projection. In 2025 alone, there were 2.2 million disputes filed.
What the data show about IDR payment awards
In many cases, providers receive payments that are many times higher than what other providers are paid for the same service.
Using CMS data, Georgetown University research showed providers are regularly getting 400% above and as high as 1,000% above contracted rates. For example, a recent New York Times investigation reported that an assistant surgeon received $50,456 through the IDR process for a prostate removal procedure, while the in-network surgeon performing the operation was paid $1,843.
These payment amounts raise concerns that providers could have less incentive to join networks and more of an incentive to seek higher reimbursement rates through the IDR process instead. Patients and employers ultimately bear these costs through higher insurance premiums.
What is ineligible under the No Surprises Act?
Not every payment dispute qualifies for the federal IDR process. Common types of ineligible disputes include:
- Services payable under Medicare, Medicaid, the Children's Health Insurance Program (CHIP), or TRICARE — these are covered by other federal programs and fall outside the Act's scope
- Disputes that were already resolved and resubmitted — duplicate filings that re-enter the system without new grounds
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- Disputes involving in-network providers — the Act applies to out-of-network scenarios, not contracted provider relationships
- Disputes subject to state surprise billing laws — states with their own protections take precedence over the federal process
- Disputes initiated before the mandatory 30-business-day open negotiation period has ended
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Blue Cross Blue Shield Association's proposed reforms to the No Surprises Act payment dispute process
Policymakers and stakeholders have proposed reforms aimed at reducing ineligible disputes, increasing transparency and strengthening oversight. Reforms are needed to preserve patient protections established by the No Surprises Act while reducing waste and unnecessary healthcare costs for patients, families and employers. To preserve No Surprises Act protections against out-of-network balance billing, we need specific solutions that:
- Discourage ineligible disputes: Introduce an upfront eligibility fee to discourage improper filings and encourage the independent dispute resolution entities (IDREs) that hear the cases to appropriately determine cases ineligible. Currently, IDREs are only compensated for cases deemed eligible.
- Increase transparency: Require arbitrators to share submissions and provide detailed rationales as part of the final decisions.
- Allow appeals: Create a formal process for parties to challenge IDR case eligibility and final payment determinations before CMS.
- Strengthen oversight: Establish metrics and accountability measures for IDREs, including corrective actions for not following appropriate practices or adhering to CMS guidance.
- Address repeat abuse: Track patterns of improper filings by providers and vendors to identify and deter manipulation of the process.