Bill would drive more IDR waste, fraud, and abuse harming consumers and employers
The No Surprises Act is already protecting millions of Americans from surprise medical bills. While the core patient protections of the law are not at issue, a handful of private equity-backed providers and IDR middlemen are abusing the law’s Independent Dispute Resolution (IDR) process, creating an affordability crisis out of a law intended to safeguard consumers.
Congress is now considering adding new costs to an IDR system that is already generating excessive and inflated awards to out-of-network providers and certain private equity firms at the expense of employers and consumers.
The NSA Enforcement Act (H.R. 4710/S. 2420) is not a patient protection bill, nor would it address any of the current IDR issues, including the exorbitant cost, inflated awards, or the root causes of delayed payments. Instead, the bill risks rewarding out-of-network providers and IDR middlemen that exploit the process at Americans’ expense.
Here’s why policymakers should oppose it:
- CBO is warning that IDR is already driving up costs.
Millions of Americans and employers are bearing the exorbitant cost of IDR — more than $5 billion from 2022 to 2024 — as the process has become a magnet for waste, fraud, and abuse. The Congressional Budget Office is now sounding the alarm on IDR. In a recent call for new research, CBO warned that “arbitration outcomes could lead to higher prices over time” and that IDR disputes “could have an outsized effect on bargaining” — raising premiums and, in turn, enlarging federal deficits. A law sold to Congress as a deficit reducer is now, by CBO’s own account, at risk of doing the opposite. The NSA Enforcement Act doubles down on that broken system instead of fixing it.
- The NSA Enforcement Act does nothing to stop the flood of ineligible claims and runaway awards.
The bill ignores the actual problems with IDR — and the problem actors. In the first six months of 2025, nearly 40 percent of disputes going through IDR were challenged as ineligible — disputes that were for Medicare, Medicaid, or state-based claims. Yet, IDR entities, which profit from disputes being finalized, ruled only 17 percent of cases ineligible during that time. That means more than half of challenged cases wrongly resulted in binding payment determinations that favor providers nearly 90 percent of the time.
At the same time, recent investigations by The New York Times have found that out-of-network doctors are capitalizing on IDR by demanding exorbitant IDR awards that have little resemblance to market-based rates. In one example, an assistant surgeon was paid more than $22,000 an hour for a 4.5-hour operation.
The NSA Enforcement Act would do nothing to stop the flood of ineligible claims, runaway awards, and ballooning administrative costs — it would simply add penalties and interest on top and encourage bad actors to file more disputes.
- It accelerates consolidation and squeezes out independent doctors.
This bill is bad for independent doctors who want to stay independent. CBO found that “large organizations dominate arbitration activity, potentially disadvantaging smaller providers and encouraging consolidation.” As private equity takes over more practices, it becomes harder for independent physicians to compete — a consolidation spiral the NSA Enforcement Act would accelerate by handing the biggest, best-financed players even more leverage.
- It creates new junk fees that hit families and employers.
Americans are already struggling with high prices, and this bill would pile on new junk fees. The NSA Enforcement Act would impose new financial penalties — with interest — on employers and health plans for delays in IDR payments, even when those delays stem from arbitrators failing to provide the information needed to process a claim. Worse, these penalties could apply even to claims that are ineligible or have already been paid through a state process. Those costs don’t disappear — they get passed on to workers and families, making it even tougher to balance household budgets.
Policymakers should prioritize solutions that address IDR’s problems.
Rather than doubling down on a broken process, the Trump administration and Congress should take immediate, commonsense steps to make sure the No Surprises Act lives up to its intended goals, including:
- Establishing clear guardrails for IDR entities to make payment determinations that reflect the cost of the service provided, not inflated amounts far beyond any market rate;
- Closing loopholes that some providers game to use IDR for services not appropriate for arbitration, by tightening the ancillary-services and eligibility definitions to keep scheduled and non-surprise care out of IDR;
- Requiring IDR entities to issue comprehensive and transparent information on determinations;
- Screening eligibility automatically through the IDR Gateway Portal before assigning an IDR entity to a dispute;
- Addressing bad-faith initiation of disputes by establishing an upfront IDR eligibility fee and penalties for patterns of abuse by providers; and
- Establishing IDR entity performance metrics and enforcing greater accountability and oversight as part of meaningful certification and recertification standards.
Congress should reject the NSA Enforcement Act and pursue commonsense reforms that lower costs for consumers and employers. Learn more here.
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