Common Questions About the IDR Process

No. Before the law was enacted patients and providers bore tens of billions of dollars in costs. When patients had encounters with out-of-network providers, they could face large medical bills for that care, leading to out-of-pocket costs and the potential for bankruptcy. Providers also had large costs for uncompensated and undercompensated care when patients failed to pay for services.

Those specific costs and personal bankruptcies have largely been eliminated by the NSA. In fact, many stakeholders, including health plans, acknowledged that the law will save consumers significant amounts of money. Further, compared to traditional dispute mechanisms such as litigation or arbitration, the IDR process is highly cost-effective, saving money for all stakeholders — particularly consumers. The cost to parties of resolving payment disputes through the IDR process is typically less than $1,500 per dispute, and in many instances even lower. Thus, compared with the costs of other plan-provider disputes such as litigation (which is historically how these disputes were resolved), the IDR process saves significant amounts, benefiting all stakeholders, and reducing costs for consumers.

No.  The cumulative number of cases going through the system over the past four years reflects the number of surprise bills that patients have now avoided, and the number of cases between out-of-network providers and health plans that need to be resolved. The volume is neither excessive nor insufficient; it simply reflects the number of disputes that must be considered. The insurance industry estimates that in 2024 there were tens of millions of out-of-network claims in total, only about 7.5-8 million of which were eligible to go through the IDR process.  Of that, only 2.5 million claims actually went through the IDR process, meaning that 70% were resolved by the Plans and the providers without any third-party assistance or during the mandatory 30-day good faith negotiation period preceding the formal arbitration process.  In light of this data, the program in 2026 should hit its natural expected volume of claims.

A 2021 CMS estimate led Congress to publish an expectation of approximately 17,000 claims per year through the IDR system. That estimate, however, was based on the experience of one (New York) state program, which operated in a very different manner than the NSA. As a result, the early estimate was not an accurate predictor of how the federal program would work. Further, as would be expected of any new federal program, the number of cases going through the IDR program has increased over time as parties gained experience with the program. 

As with any new program, the IDR process has needed to grow and develop systems and efficiencies. A backlog of disputes developed in 2023-24 following the large influx of new disputes and multiple, litigation-related pauses imposed by CMS. However, once the program resumed, IDR entities rapidly cleared most of the accumulated cases. Today, many IDR entities are meeting CMS timeliness expectations for processing disputes.

IDR Entities must, by law,  select the offer that best represents the value of the IDR item or service, taking into account criteria set by Congress (which are known by the parties). Congress created a “baseball style” arbitration process through which each side of the dispute submits one offer, which is measured against specific statutory criteria set by Congress. The IDR entity cannot compromise between offers.

Given that providers often initiate cases when they cannot resolve their claims informally, it is expected that the providers would only bring those claims that they expected to win.  In other words, the cases actually brought to the formal process can be expected to be “cherry-picked” to be winning claims before they were brought. 

No, at the time the NSA was enacted an estimated 90% of treatments were provided by in-network providers, and in 2026 the Government Accountability Office found that since the IDR process was implemented, provider in-network participation rates have increased from 90% to 93%.  If there is a cause and effect, the NSA is driving more providers to go in-network.

The process only applies to providers who were out-of-network when they treated the patient and, by definition, did not agree to any in-network rate. Moreover, Congress set the criteria for payment using multiple factors beyond the "Qualifying Payment Amount" (QPA) that plans historically paid in-network providers. In other words, Congress intended awards to exceed typical in-network rates, and the awards have been consistent with Congressional design.  Notably, before the No Suprises Act was passed out-of-network emergency physicians have charged rates far exceeding their in-network counterparts, averaging 637% of Medicare rates compared to 266% for in-network emergency physicians for identical services.  Under the No Suprises Act, median prevailing provider offers in emergency service disputes across 14 states have been documented at 312% of QPA, median prevailing offers across all dispute types in the first half of 2024 ranged from 383-447% of QPA depending on the data source, and when payers prevail, the average payment is approximately 110% of QPA.

Yes, but they are being weeded out. The eligibility criteria are complex, and parties are still filing ineligible claims. IDR entities must currently identify and dismiss these claims. CMS is working on a regulation to streamline the eligibility process and CIDRE hopes that the regulation will be finalized soon.  But the ineligibility screening process has integrity as CMS has the right to audit IDR entity screening and all IDR entities are subject to recertification on a regular basis, allowing CMS further oversight of IDR entities’ adherence to program requirements.

No. IDR entities are appropriately compensated for the work that they do, and they take seriously their responsibility to adhere to program requirements, but they do not let their financial interests confuse their obligations under the law, just as the vast majority of providers and Plans do not do so when working with patients.  Further, CMS plays a role in policing the process to ensure that no ineligible claims are decided.  IDR entities today already reject a healthy percentage of cases filed (for which they are not compensated), and that figure is expected to drop as parties gain more experience with the process and reduce the filing of ineligible claims in the future.

Yes. Due to a 2025 court decision, prevailing parties to an IDR decision do not have the right to enforce their judgment in court, and it is up to CMS to create the enforcement process when a party chooses not to honor the IDR entity award.