A new Health Affairs article published by researchers at Georgetown University’s Center on Health Insurance Reforms and released as a companion article to an earlier analysis, highlights alarming inconsistencies in how arbitrators are resolving payment disputes under the No Surprises Act. Drawing on new data from the Centers for Medicare & Medicaid Services (CMS), the analysis found wide variation in arbitrator decisions—one siding with providers 99 percent of the time.
Findings indicate that Independent Dispute Resolution (IDR) entities with the highest case volumes are disproportionately more likely to side with providers, undermining the validity of the process and further reinforcing calls for greater transparency, oversight, and reform to ensure the arbitration system functions as intended.
Below are key insights from the analysis. To read more, click here.
IDR entities differed significantly in how often they ruled in favor of providers.
- “Four IDR entities favored providers in more than 90 percent of cases resolved in the first half of 2024, while one IDR entity favored providers in only one-third of cases.”
- “For one IDR entity in one year, the share of disputes ruled in favor of providers was as high as 99 percent. Conversely, the lowest share across years and IDR entities was 19 percent, an 80 percentage-point difference.”
Decision patterns were influenced by case volume, which varied substantially across entities.
- “The share of cases appears correlated with determination outcomes: the IDR entities that rule in favor of providers tend to have higher case volumes.”
- “For example, the top IDR entity for resolved cases initiated in Q1-Q2 of 2024 decided more than 90 percent of cases in favor of providers. The lowest volume IDR entity had less than 1 percent of all disputes and determined only one-third in favor of providers.”
Time to resolution has improved overall, though average determination times still differ by entity.
- “In 2024, while the overall average dropped to 54 days, the highest-volume IDR entities averaged 51 and 80 days.”
- “Only one IDR entity had an average (31 days) close to the statutory time to determination of 30 days.”
Variability across IDR entities underscores a need for greater transparency.
- “The volume of ineligible cases continues to be high as well, raising concerns that ineligible cases are contributing to system inefficiency. Given that IDR entities determine case eligibility and are only paid for eligible cases, some stakeholders suggest that IDR entities are incentivized to determine ineligible cases as eligible.”
- “The IDR system needs a more effective means of screening out ineligible claims, but IDR entities may not be ideally positioned for this task. Proposed rules that are pending at the federal agencies should help address delays in eligibility determinations, but would not resolve incentives for IDR entities to determine eligibility.”
- “Better education, training, and oversight of IDR entities and their decision-making might help reduce some of the uncertainties in the current process and boost confidence for both the contesting parties and the wider community interested in the impact on costs and premiums that the amounts paid are as fair as possible.”
The big picture: The IDR system under the No Surprises Act is increasingly marked by inconsistent decisions, limited transparency, and growing opportunity for manipulative behavior. Arbitrators vary widely in how they rule, often offering minimal rationale, while high-volume, provider-aligned entities dominate the process. The analysis underscores the urgent need for a more robust IDR operations rule—one that ensures consistent standards, stronger oversight, and alignment of incentives—to restore credibility and protect consumers from rising health care costs.
For more information on the No Surprises Act, visit stopsurprisebillingnow.com.
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