New data on No Surprises Act IDR cases show providers won often in 2025

Providers and their intermediaries continued to flourish in the No Surprises Act’s independent dispute resolution (IDR) process during the second half of 2025, according to newly released data from the federal departments overseeing IDR.

Among 1.15 million disputes that received payment determinations during the six-month period, providers won 85%. That share generally tracked trends seen during the first half of the year, when providers prevailed in 88% of cases, the Departments of Labor, Treasury and Health and Human Services reported July 22.

Awards exceeded the qualifying payment amount (QPA) in 87% of payment determinations during the six-month period. The QPA is the insurer’s median in-network payment rate for the service in the particular metropolitan statistical area.

With insurers generally basing their initial out-of-network (OON) payment offers on the QPA benchmark, according to the federal departments, providers usually come out ahead by turning to IDR after negotiations reach a standstill. The baseball-style arbitration proceedings require the provider and insurer to each submit a final offer, with the arbitrator choosing between the two.

Emergency services generate a large share of decisions

Emergency services comprised the majority of settled disputes (52%), followed by radiology (15%). There were nearly 633,000 IDR payment determinations for emergency services, with median awards relative to the QPA of 324% in Q3 and 296% in Q4, according to supplemental tables.

Other categories of service had fewer disputes but higher final payments, relative to QPA — more than 10 times greater in a few instances. For example, median IDR payment decisions for surgery were 1,449% of QPA in Q3 and 1,279% in Q4 among more than 238,000 decisions.

Neurology and neuromuscular procedures made up nearly 160,000 decisions and had median payment amounts totaling 2,394% of the QPA in Q3 and 1,938% in Q4.

A majority of payment decisions (718,808) during the second half of the year were for services for which the QPA was between $100 and $500.

Dispute filings edged higher in Q3 and Q4 2025

There were more than 1.37 million disputes filed during the second half of the year, representing a 16% increase over the first six months. More than three-quarters of disputes (76%) were initiated by clinical providers, with a growing share (24%) initiated by facilities.

The top three initiating parties — HaloMD, TeamHealth and SCP Health — accounted for 38% of all filings, as those types of companies continue to generate a significant share of IDR activity. TeamHealth and SCP Health are medical staffing groups, while HaloMD is a technology and administrative services intermediary.

The success of HaloMD in particular has led multiple insurers to bring litigation challenging the company’s IDR strategy, alleging misuse and excessive use of the IDR system. Cases were filed in California by Elevance (then known as Anthem) and in Texas and Georgia by Blue Cross Blue Shield plans.

Insurers have fallen short thus far, with federal judges dismissing the cases and stating that the No Surprises Act establishes IDR awards as final and binding.

“It is highly improbable to infer from these facts that there is a vast conspiracy of providers and IDREs [independent dispute resolution entities] that have conspired to defraud the Plaintiff of millions of dollars in thousands of NSA [No Surprises Act] IDR proceedings over many years,” wrote Judge Thomas Thrash Jr. (a Clinton appointee) of the U.S. District Court for Northern Georgia. “It is highly plausible to infer that the Plaintiff engages in a consistent practice of submitting lowball offers to out-of-network providers in an effort to maximize its profits.”

The cases were dismissed with prejudice, meaning the legal claims by the insurers cannot be modified and reintroduced in new trials. However, appeals are underway or have been announced, and cases are pending in Pennsylvania and Ohio.

IDR entities increased throughput and reduced the backlog

Although dispute volume continued to climb during the six-month period of the new report, operational performance appeared to improve substantially, with certified IDR entities closing nearly 1.5 million disputes to reduce a longstanding backlog.

During the second half of 2025, 62% of payment determinations happened within 30 business days, compared with 37% in the year’s first half. Operational improvements included the addition of two certified IDR entities (i.e., arbitrator organizations); enhanced automation of the portal, especially for eligibility checks; and better validation tools.

Eligibility determinations remained the biggest bottleneck, with more than 42% of disputes challenged by the non-initiating party as being ineligible. Ascertaining eligibility remains resource-intensive because arbitrators must evaluate whether disputes satisfy all statutory and regulatory requirements before reaching a payment decision, the departments have noted.

The departments reported improvement in that area through operational changes, such as requiring additional information from the parties when they file a dispute and implementing screening protocols to identify duplicate disputes. Those changes helped reduce the share of disputes ruled ineligible from 69% back during the first half of 2022 to 19% during the second half of 2025.

CMS also has noted that recently finalized regulations are intended to further improve eligibility processes (even though a $100 reduction in the administrative fee could make small-dollar disputes more worthwhile to pursue).

Common reasons for ineligible disputes these days, according to the federal departments, include violations of the 90-day cooling-off period that blocks a party from immediately filing a dispute about the same or similar services with the same party following a decision. Another frequent issue arises when disputes are submitted to the federal portal even though they should have been resolved based on state surprise-billing laws.

Texas continues to lead in federal IDR action

Texas has been the hotbed of IDR activity for most of the portal’s four-year existence and remained that way during the second half of 2025, according to the new statistics. The state had 524,630 disputes initiated, while no other state reached six figures.

Texas is home to large emergency physician, anesthesiology and radiology groups, and those are among the services where the No Surprises Act is most likely to apply based on the prevalence of out-of-network care furnished at in-network facilities.

Advocates in Texas have pursued litigation to help ensure providers can use the IDR system to obtain OON payments that align with historical rates. The Texas Medical Association scored several victories in court over the past few years, including decisions that deemphasize the QPA as the central factor in IDR decisions and affect how the QPA is calculated.