New federal data shows the independent dispute resolution process created under the No Surprises Act is being used more than ever. Total federal IDR disputes rose from 653,445 in Q3 of 2025 to 719,118 in Q4 of 2025 — a roughly 10% jump.
One state is driving an outsize share. According to CMS’ IDR Supplemental Tables for Q3 and Q4 2025, Texas generated more arbitration disputes than the next nine states combined.
Here are the 10 states with the most arbitration disputes.
Ranked by total disputes initiated (emergency/non-emergency items plus air ambulance):
1. Texas: 280,355 Q4 disputes (+14.8% from Q3)
Texas accounted for roughly 39% of the entire national dispute total in Q4, up from about 37% in Q3, and posted both the largest raw count and one of the largest growth rates of any top-10 state. BCBS Texas alone was the target of 129,662 of those disputes, making it the second most-disputed health plan behind only UnitedHealthcare.
2. Arizona: 44,934 Q4 disputes (+5.2% from Q3)
Arizona has held the No. 2 spot in both quarters.
3. Florida: 40,377 Q4 disputes (+2.9% from Q3)
Florida’s growth was the slowest of the top 10, essentially flat quarter over quarter.
4. California: 38,053 Q4 disputes (+17.6% from Q3)
California posted the fastest growth rate of any state in the top 10 — even faster than Texas’.
5. New Jersey: 37,151 Q4 disputes (+4.1% from Q3)
New Jersey slipped to fifth as California’s faster growth overtook it, even though New Jersey’s own dispute count also rose.
6. Georgia: 27,584 Q4 disputes (+8.5% from Q3)
Georgia grew faster than the top-10 median, separated by fewer than 400 disputes in Q4.
7. New York: 27,232 Q4 disputes (+9.7% from Q3)
New York posted one of the higher growth rates among the top 10.
8. Tennessee: 23,778 Q4 disputes (+3.3% from Q3)
Tennessee stands out for its air ambulance volume specifically: 1,117 air ambulance disputes in Q4, the second-highest count of any state after Texas, and up from 912 in Q3.
9. Indiana: 19,079 Q4 disputes (+1.5% from Q3)
Indiana’s growth was among the flattest in the top 10, holding at No. 9 in both quarters with only a modest increase in volume.
10. Louisiana: 17,992 Q4 disputes (+4.5% from Q3)
Louisiana rounded out the top 10 in both quarters. Its growth rate came in below the approximately 10% national average, meaning its share of the national total shrank slightly even as its raw dispute count rose.
Why Texas?
Texas commonly leads in IDR disputes. A few things explain the pattern:
- One payer draws an outsize share of disputes.
BCBS Texas was the second most-disputed health plan in the country in both Q3 and Q4 2025 (108,285 and 129,662 disputes, respectively), trailing only UnitedHealthcare.
- Texas already had an arbitration habit before the federal law existed.
In the year before the federal IDR process took effect, Texas’ own state-level balance-billing arbitration system — which had no benchmark rate to anchor settlements — generated roughly 49,000 dispute requests on its own.
- The state has a large self-funded employer market.
Self-funded plans fall under federal rather than state jurisdiction and must use the federal IDR process. They also are consistently the largest category of disputed plans nationally. In Texas, 61.9% of privately insured workers were in self-funded plans in 2024, above the 57% national average; combined with Texas’ status as the second-most-populous state, that gives it one of the largest self-funded workforces in the country in absolute terms.
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