While the arbitration process established under the No Surprises Act is designed to protect patients from unexpected, out-of-network charges, a new analysis finds that managing these disputes is proving costly, too.
The independent dispute resolution process, or IDR, is built on baseball-style arbitration to determine how much a provider will be paid for out-of-network claims and had been embraced in some states before the legislation established it as a federal process.
In the study published this week in Health Affairs, researchers from Georgetown University estimate that between 2022 and 2024, the IDR system cost $5 billion to manage. The largest chunk of that is the additional payments from plans to providers, totaling $2.24 billion.
That figure also accounts for $1.9 billion in internal costs for payers and providers as well as $656 million in IDR entity fees. Administrative fees were $228 million, according to the analysis.
Administrative fees are paid to federal agencies to support the IDR system, while IDR entity fees are paid to the independent organizations that conduct arbitration, according to the study.
"The high volume of IDR disputes is generating significant spending from administrative costs and higher payments for services," the researchers wrote. "This higher spending will likely be reflected in higher overall health costs and consumer premiums in the future."
The report notes that the number of disputes that reach independent resolution continues to outpace expectations from the feds. Agencies estimated that 17,333 disputes would go through the process each year, with an additional 4,899 IDR disputes related to air ambulances.
However, between mid-2022 and May 2025, there were 3,324,051 filed, including those from air ambulances. In the first nine months of the arbitration system's existence, 190,000 disputes were filed, more than 10 times federal estimates.
Resolution rates have also increased over time, growing from 29% at the end of 2022 to 41% a year later. Most (85%) of disputes had been resolved as of May 2025, according to the report.
That said, the sheer number of disputes reaching IDR has made it "nearly impossible" for entities to meet the 30-day deadline for payment determinations. At the end of 2024, the median length of time taken to reach a determination for line-item claims was 81 days.
The median length of time required had peaked at 96 days, according to the study.
"Although volume is likely the main reason for delays, delays were exacerbated by pauses when adverse court decisions forced the agencies to review procedures," the researchers wrote.
The study also found that a small number of providers continue to account for the lion's share of disputes. Radiology Partners and its affiliates accounted for 28% of disputes in 2023 and 2024, with TeamHealth accounting for 15%. The top five providers collectively represented 59% of line-item claims.
The median payouts earned through IDR have also grown, according to the report. In the fourth quarter of 2024, the median payment determination was 459% above the qualifying payment amount.
"These trends prompt the question of whether steps should be taken to reduce IDR use and the size of the awards and what policy levers are available," the researchers said.