The No Surprises Act: Independent Dispute Resolution for Planned Procedures
This analysis examined Independent Dispute Resolution (IDR) determinations for planned surgical and endoscopic procedures from 2024 through early 2026. Providers won nearly 90% of disputes, with provider payments (awards) far exceeding benchmarks that reflect in-network commercial rates and Medicare rates.
The No Surprises Act (NSA) protects patients from unexpected medical bills and established an IDR process to resolve payment disputes between plans and providers for certain out-of-network services. This study analyzed awards for 7,304 disputed claim lines involving planned procedures, including spine surgery, plastic surgery, and endoscopic services that went through the IDR process.
Providers prevailed in most disputes and awards were extreme, averaging more than 50 times benchmarks that reflect in-network commercial rates and Medicare rates. The findings suggest that policy changes are needed to ensure that the NSA does not contribute to rising healthcare costs, particularly for planned out-of-network care that should not be a “surprise” for patients.
Related Public Policy Research
Arbitration Outcomes for Out-of-Network Medical Bills Under the No Surprises Act
This study, published in INQUIRY: The Journal of Health Care Organization, Provision, and Financing, compared final payments for out-of-network care from disputes that underwent arbitration under the No Surprises Act in 2023 to commercial in-network rates and Medicare rates.
Provider Charges and State Surprise Billing Laws: Evidence from New York and California
This study published in Health Affairs examined how out-of-network (OON) provider charges changed following the passage of New York and California’s surprise billing laws compared with states without a surprise billing law.
Estimating Surprise Bills Among Members of Commercial Health Insurance
Potential surprise bills occurred for 1.8 percent of members and 6.2 percent of episodes in 2018. Emergency episodes had a higher rate of potential surprise bills than non-emergency care.