By Jack Hoadley, Kennah Watts, Katie Keith, and Ellie DeGarmo
Greater than 5 years in the past, President Trump signed the No Surprises Act into regulation, newly defending sufferers from a number of the most pervasive forms of shock out-of-network payments. The regulation has efficiently protected hundreds of thousands of shoppers from the scourge of surprising out-of-pocket prices. However implementation of the unbiased dispute decision (IDR) course of—i.e., the mechanism put in place by Congress for suppliers and payers to resolve disputes over out-of-network charges—has been affected by excessive quantity and excessive prices that would undermine the financial savings Congress anticipated when the No Surprises Act was enacted.
Constructing on our prior findings for IDR outcomes, this text gives an early have a look at publicly accessible IDR-related information from the primary two quarters of 2025. Total, the information present a big uptick within the quantity of IDR instances and corresponding administrative prices. This text additionally gives a short replace on latest developments in litigation over the No Surprises Act, which has contributed to a extra expensive IDR system. Certainly, many lawsuits in the latest wave of litigation—wherein payers are suing high-volume IDR middlemen and suppliers—mirror allegations which can be in line with the developments noticed within the information beneath.
The Quantity Of IDR Disputes (And Prices) Continues To Rise
As reported by the Facilities for Medicare and Medicaid Companies (CMS) in supplemental tables and public use information, the amount of instances submitted into the IDR course of continues to exceed all expectations and grew quickly within the first six months of 2025. Throughout that interval, events submitted 1.2 million new disputes to the IDR portal—greater than double the amount of the first two quarters of 2024 when almost 590,000 disputes had been filed. This quantities to a complete of three.4 million disputes from 2022 via June 2025.
And the variety of disputes is barely persevering with to extend: Much more latest bi-monthly updates from CMS present that almost 1.4 million instances had been filed from July 2025 via December 2025. This has resulted in a whopping 4.8 million whole instances via the tip of 2025. As a reminder, federal officers anticipated roughly 17,000 disputes per yr.
The ever-increasing quantity of instances has contributed to larger administrative prices. IDR administrative prices embody two charges for every dispute: an administrative price and a price paid to IDR entities, that are unbiased third-party arbitrators accountable for making cost determinations when suppliers and plans can not attain an settlement on their very own. Within the first half of 2025, these charges totaled $844 million. This quantity is staggering by itself. However it’s much more alarming that this quantity—for a six-month interval—is sort of equal to the overall of $885 million in administrative charges from 2022 to 2024.
The excessive price quantity in simply six months means that IDR-related administrative prices are escalating shortly and that our prior estimate of $5 billion in whole IDR-related prices via the tip of 2024 could have risen considerably by the tip of 2025. This could be true even earlier than accounting for larger payment-related prices.
As quantity continues to rise, IDR entities have grown extra environment friendly. Within the first six months of 2025, IDR entities—together with three newly licensed IDR entities—closed 155,000 extra disputes than had been filed. Regardless of this progress, a backlog stays with 430,000 disputes nonetheless excellent as of late June 2025. The IDR course of additionally continues to take extra time than anticipated, with two-thirds of determinations exceeding the required 30-day interval for decision.
Massive Supplier Teams And Middlemen Proceed To Prevail
In keeping with prior developments, suppliers continued to provoke (and win) the overwhelming majority of disputes. Within the first six months of 2025, suppliers and amenities initiated 99.9 % of all disputes whereas plans initiated 0.01 %. Of the provider-initiated disputes, 80 % had been submitted by suppliers whereas 20 % had been submitted by amenities. The majority of those disputes had been initiated in opposition to solely a handful of insurers: greater than half (57 %) of all disputes had been filed in opposition to UnitedHealthcare, Blue Cross Blue Protect of Texas (a subsidiary of the Well being Care Service Company), and Aetna.
4 supplier teams and supplier representatives—principally backed by personal fairness—initiated the vast majority of these disputes: HaloMD, Staff Well being, Radiology Companions, and SCP Well being. HaloMD—a intermediary group that makes a speciality of arbitration—initiated probably the most disputes, accounting for 17 % of all disputes within the first quarter of 2025 and 22 % of all disputes within the second quarter of 2025. For a company that initiated a mere 1 % of line-item claims in 2023, this can be a speedy rise to prominence. The second most frequent initiator, Staff Well being, has lengthy been a high-volume IDR participant and initiated 16 % of all disputes within the first six months of 2025, a degree that’s in line with prior years. Mixed, the highest 4 initiators accounted for greater than half (56 %) of disputes filed within the first two quarters of 2025.
Suppliers additionally received 88 % of disputes—the very best supplier win price so far—as in comparison with 85 % in 2024 and 81 % in 2023. Radiology Companions prevailed most frequently, profitable favorable IDR awards in 92 % and 95 % of its instances within the first two quarters of 2025, respectively. Staff Well being noticed related win charges of 94 % throughout each quarters. HaloMD received barely much less typically however nonetheless prevailed in 87 % and 82 % of its disputes within the first two quarters of 2025, respectively.
Ineligible Disputes And Default Choices
Plans and suppliers proceed to disagree about whether or not and which claims are eligible for the federal IDR system. Within the first half of 2025, plans challenged 40 % of instances as ineligible, just like previous years. The IDR entities deemed almost a fifth (17 %) of disputes ineligible, a slight discount from prior quarters, which federal officers attribute to enhancements to eligibility evaluation processes. The persistence of ineligible disputes might consequence from miseducation or misaligned incentives for IDR entities, and federal officers acknowledge that ineligible disputes are “cluttering up the method.”
Past ineligible disputes, 22 % of IDR determinations within the first six months of 2025 resulted from default selections (i.e., the place just one occasion submitted their provide and paid their charges). That is just like the speed in earlier quarters. However it’s regarding that greater than one-fifth of determinations proceed to be determined by default even after a number of years of IDR operations.
Plans Look To Aid From The Courts
Citing considerations concerning the quantity of allegedly ineligible disputes and different IDR practices, plans have more and more turned to the courts to sue IDR gamers. The first of those lawsuits was filed in December 2024, and extra shortly adopted. As of this writing, we’re formally monitoring 9 such instances, and we’re conscious of a number of others—together with, as an example, new lawsuits filed by UnitedHealthcare entities in opposition to IAS Arizona and Harmony Firm of Tennessee on January 30 and a brand new lawsuit filed by the Well being Care Service Company in opposition to Neuromonitoring Associates on February 18.
Certainly, there are pending lawsuits in opposition to many of the entities which can be accountable for initiating the vast majority of IDR disputes. This consists of a minimum of 4 lawsuits in opposition to HaloMD (in California, Georgia, Ohio, and Texas); a minimum of one lawsuit in opposition to Radiology Companions (in Florida); and a minimum of one lawsuit in opposition to SCP Well being (in Virginia). These challenges have been filed by Aetna and Anthem/Blue Cross Blue Protect associates, amongst others. We’re additionally conscious of a minimum of one shareholder lawsuit in opposition to an organization for its alleged use of HaloMD as a vendor.
Typically, plans assert that IDR middlemen and suppliers have “weaponized” the federal IDR system. How? By deliberately flooding the federal IDR system with claims that aren’t eligible for IDR beneath the No Surprises Act in an try and overwhelm the system, receive default awards, and maximize reimbursement. The plans increase quite a lot of claims however typically allege that this conduct quantities to fraud, misrepresentation, and a violation of state and federal legal guidelines such because the federal Racketeer Influenced and Corrupt Organizations Act and the Worker Retirement Earnings Safety Act.
Anthem, for instance, sued HaloMD in California, alleging that greater than half—55 %—of HaloMD’s dispute submissions had been ineligible for the IDR course of and resulted in hundreds of thousands of {dollars} in improper funds to suppliers. HaloMD was capable of file ineligible claims, Anthem alleges, by deliberately ignoring IDR system guardrails that had been meant to stop ineligible claims from being submitted. The grievance describes the federal IDR portal submission course of intimately—screenshots and all—to allege that HaloMD knowingly made deliberate misrepresentations when submitting ineligible disputes via the IDR system.
Maybe unsurprising given the amount of disputes we’re seeing—and the {dollars} which can be on the road—different stakeholders are partaking within the judicial course of even when not a celebration to the lawsuit. In Anthem’s lawsuit in opposition to HaloMD, the California Medical Affiliation filed an amicus temporary in assist of HaloMD whereas AHIP and a coalition of employer teams led by the American Advantages Council filed amicus briefs in assist of Anthem. The latter temporary explains that the continued widespread misuse of IDR will sharply enhance prices for employers and staff.
As one other instance, Anthem Well being Plans of Virginia sued SCP Well being and others in November 2025. Anthem asserts that almost 60 % of the extra than27,000 disputes defendants initiated in opposition to it since 2024 had been ineligible for IDR beneath the No Surprises Act. As an example, of the 954 disputes submitted by SCP Well being in a single day, Anthem alleges that 943 had been ineligible for IDR. Even so, the plan misplaced 329 of those disputes and was ordered to pay a further $340,000 in funds (over the unique reimbursement) and $182,000 in administrative charges.
This grievance additionally highlights variations in outcomes between the federal IDR course of and Virginia’s state-level IDR system. From Might 2024 to Might 2025, Virginia’s IDR system dealt with simply 252 instances. In roughly that very same time interval, there have been greater than 34,000 Virginia instances filed within the federal IDR system based on CMS information. Moreover, whereas suppliers prevailed in 85 % of federal IDR disputes in 2024, suppliers prevailed in solely 45 % of IDR disputes when utilizing Virginia’s IDR system (from Might 2024 to Might 2025). Anthem attributed these extra balanced outcomes to specific guardrails on Virginia’s IDR course of and steerage from state officers.
Virginia just isn’t alone on this expertise. A lot of the 10 states with state IDR programs the place experiences can be found see far fewer instances than the federal IDR system. The one exception is Texas, the place stakeholders initiated greater than 500,000 instances in the latest reporting yr. Even there, most of those disputes—about two-thirds—had been settled inside the 30-day negotiation interval previous to arbitration or mediation and thus didn’t proceed via the complete IDR course of.
Extra balanced IDR outcomes are additionally not distinctive to Virginia’s IDR system. State-level arbitration information present that suppliers win a majority of instances in most states however typically much less incessantly than within the federal system. For instance, supplier win charges had been about 66 % in New Jersey and about 60 % in Washington however about 81 % in New York. The expertise in states throughout the nation means that IDR can produce extra balanced outcomes however that extra guardrails could also be wanted on the federal IDR system.
Suppliers Proceed To Win Excessive Award Quantities
Award quantities additionally proceed to develop. CMS’s information consists of the provide quantities from every occasion and the prevailing provide expressed as a share of the qualifying cost quantity (QPA). The QPA is designed to symbolize the median in-network price for every insurer and is used because the benchmark for reporting on cost determinations beneath the No Surprises Act.
For the primary two quarters of 2025, Radiology Companions secured median awards of 582 % and 594 % of QPA, respectively. SCP Well being received median awards of roughly 370 % of QPA in each quarters, and Staff Well being received award quantities at a median of 277 % of QPA. Of the highest 4 initiating events, HaloMD’s award quantity far outpaced the others, with median funds of 920 % and 835 % of QPA within the first two quarters of 2025, respectively. To the extent that the QPA precisely represents median in-network charges, these outcomes point out that sure supplier teams are receiving three to 9 occasions in-network charges.
Whilst suppliers safe excessive awards via IDR, suppliers have questioned the QPA’s accuracy in representing the in-network price and challenged the federal authorities’s QPA methodology. All eyes stay on a lawsuit filed by the Texas Medical Affiliation and LifeNet that’s pending earlier than the Fifth Circuit Court docket of Appeals. As mentioned in additional element right here, the complete panel of Fifth Circuit judges is contemplating, amongst different points, whether or not the QPA methodology improperly included so-called “ghost charges” and improperly excluded case-specific agreements for air ambulance companies and bonus or incentive funds. Following oral argument in September 2025 and a request from the court docket, the events submitted supplemental briefs on “ghost charges” in January 2026. A call could possibly be issued at any time.
If the Fifth Circuit permits modifications to the QPA methodology, plans might face larger operational burdens in calculating the QPA. And, as a result of the No Surprises Act requires value sharing to be primarily based on the QPA (or in some instances, on a price decided beneath state regulation), any change that raises the QPA will result in larger affected person out-of-pocket prices for out-of-network care.
Suppliers Sue Over IDR Course of And Awards
On the similar time, and as mentioned in additional element right here, suppliers have begun suing plans over IDR awards. Certainly, we’re monitoring a number of lawsuits from suppliers who’ve sued plans to implement IDR awards and procure immediate cost. Suppliers have additionally accused payers of not totally disclosing data on the QPA as required beneath federal guidelines. In different situations, suppliers have accused IDR entities of improperly choosing the QPA as the suitable provide. A few of these lawsuits contain alleged nonpayment of IDR awards to the tune of hundreds of thousands of {dollars}. And a few suppliers commonly sue well being plans over IDR awards of which, in some situations, the plan claims to have by no means acquired discover.
Though many lawsuits have been filed, suppliers can not sue plans or IDR entities except the No Surprises Act authorizes a personal proper of motion. In virtually each occasion the place this situation has been thought-about, courts have held that suppliers do not need such a proper, together with to implement IDR awards. Most lately, the Supreme Court docket declined to listen to Guardian Flight’s enchantment of a Fifth Circuit resolution that held that the air ambulance firm didn’t have a personal proper of motion to sue the Well being Care Service Company over unpaid IDR awards. In November 2025, the Eleventh Circuit reached an analogous conclusion, discovering that judicial evaluation of IDR awards beneath the No Surprises Act is restricted to slim exceptions, comparable to fraud.
Certainly, we’re conscious of just one occasion the place a district court docket has held {that a} restricted personal proper of motion exists beneath the No Surprises Act. In Might 2025, a federal district court docket in Connecticut held that the No Surprises Act consists of an implied personal proper of motion that permits events to ask a court docket to implement IDR awards. This litigation is ongoing. Individually, a federal district court docket in New Jersey addressed judicial enforcement of IDR awards by denying a plaintiff supplier’s movement to vacate an IDR award and granting the defendant plan’s cross-motion to verify the IDR award. Every court docket emphasised that the ultimate and binding nature of IDR awards meant {that a} court docket might implement or verify IDR awards, however the New Jersey court docket stopped wanting discovering a personal proper of motion beneath the No Surprises Act.
Within the absence of a personal proper of motion, what’s a supplier to do? In response to the courts, complain to CMS. These courts have directed suppliers to a provision of federal regulation that provides the company the authority to implement plan noncompliance with the regulation. Evaluation of CMS experiences reveals that some suppliers have raised these considerations with the company, submitting almost 1,600 complaints about late funds after IDR determinations via September 2024.
The place Do Issues Go From Right here?
The latest IDR information from 2025 underscore continued considerations about rising quantity and prices related to the federal IDR system. As famous above, the amount of disputes for the primary half of 2025 is sort of double the variety of disputes from the primary half of 2024—with administrative prices that, in solely six months, are almost as excessive as the overall administrative prices from 2022 to 2024. We now have no cause to assume these developments is not going to proceed however will study extra when CMS releases full information from the second half of 2025. A full yr of 2025 information will present extra readability on developments and assist inform enhancements to the IDR system.
In the meantime, the Trump administration is poised to make its personal modifications to the IDR system. Federal officers are at the moment reviewing a draft closing rule that may tackle stakeholder considerations associated to the IDR course of. The scope of the ultimate rule just isn’t recognized, however the Biden-era proposed rule included new restrictions on batched disputes and an overhaul of the eligibility evaluation course of. These modifications might assist tackle a number of the considerations mirrored above concerning the excessive quantity of disputes and the submission of ineligible instances, particularly.
Lastly, litigation over the No Surprises Act will undoubtedly proceed. Along with ready on a choice from the Fifth Circuit on the QPA methodology, courts will proceed to grapple with the query of whether or not suppliers (or plans) have a personal proper of motion beneath the No Surprises Act. Whilst plans newly take to the courts, any judicial reduction will probably be delayed. These lawsuits take time, and we’re not conscious of a choice in a lawsuit initiated by a plan in opposition to suppliers and IDR middlemen.
Jack Hoadley, Kennah Watts, Katie Keith, and Ellie DeGarmo “The No Surprises Act IDR Course of: An Early Look At 2025 Information” March 20, 2026, https://www.healthaffairs.org/content material/forefront/no-surprises-act-idr-process-early-look-2025-data. Copyright © 2026 Well being Affairs by Undertaking HOPE – The Folks-to-Folks Well being Basis, Inc.