The No Surprises Act was built to take patients out of the middle of out-of-network billing fights. The arbitration process it created to settle those fights between insurers and providers has since become a fight of its own.
Over the past three months, payer CEOs have criticized the independent dispute resolution process on earnings calls, courts have rejected insurer lawsuits against high-volume filers, a federal appeals court has struck down part of the government’s payment methodology, and one of the law’s authors has moved to replace arbitration altogether.
Here are 10 numbers behind the latest developments:
1. 67%. About 67% of the 2.5 million disputes filed in 2025 came from 10 provider groups, according to House Energy and Commerce Committee Democrats. Rep. Frank Pallone Jr., D-N.J., one of the law’s authors and the committee’s ranking member, moved to replace the arbitration process with the Lower Premiums, Faster Payments Act, which would set a payment benchmark based on the median in-network rate and require payment within 30 days of a claim being filed. Committee Democrats also said arbitration fees reached $1.3 billion last year, compared with $885 million across 2022 through 2024 combined.
2. $1.7 million. A New York state court dismissed a lawsuit from two Long Island practices, True North Medical of Manhasset and True North Medical of Suffolk, that sought more than $1.7 million tied to 13 IDR determinations they said Anthem had not paid. Suffolk County Supreme Court Justice Paul Hennings found the No Surprises Act provides no private right of action to enforce IDR awards and that state-law claims could not fill that gap. The ruling came the same month air ambulance operator PHI Health sued Anthem over more than 1,200 IDR determinations totaling roughly $30 million nationwide.
3. $3.2 billion. The Blue Cross Blue Shield Association said in a September letter that 39% of BCBS payment determination dollars since 2022 involved ineligible services, totaling $3.2 billion, based on an analysis of more than 5.1 million lines of plan data. The association said certified IDR entities overruled plans’ eligibility objections in 69% of cases, and that the 2025 median determination was 6.4 times the qualifying payment amount.
4. $1. A majority of the Fifth Circuit’s 17 active judges sided with the Texas Medical Association Aug. 11, finding federal agencies violated the statute by letting insurers include “ghost rates” in qualifying payment amount calculations. Those non-negotiated placeholder rates can be as low as $1. The court also found the agencies could not categorically exclude bonus and incentive payments, but upheld the exclusion of single-case agreements in an air ambulance challenge.
5. 6 million. More than 6 million disputes have been filed since the federal portal opened in 2022, compared with the roughly 22,000 per year federal agencies originally projected. The Congressional Budget Office originally projected the law would cut premiums by about 1%, but said in June that emerging evidence suggests the law may not have the effects it anticipated.
6. 8 to 12 times. Anthony Maioriello, MD, of Dallas-based Comprehensive Level One Staffing, who also runs an IDR recovery firm, said the awards he sees typically run eight to 12 times insurers’ original offers. He attributed the gap to low initial offers from insurers, not provider gaming.
7. 40%. Cigna CEO Brian Evanko said on the company’s July 30 earnings call that Cigna sees “clear abuses” of the IDR process, citing “unsustainable volume levels, much of which is concentrated amongst a small number of providers.” He said the impact “has been manageable” for Cigna’s insurance business. Elevance Health has cited a 40% increase in case volume in 2025 and adopted a policy across more than a dozen states that penalizes hospitals 10% for using out-of-network providers.
8. $14.85 billion. The arbitration process awarded about $14.85 billion to providers in 2025, up from $4.08 billion in 2024, according to a Wall Street Journal analysis of federal data. Arbitration firms collected about $1.3 billion in fees. Providers, facilities and air ambulance services prevailed in about 85% of second-half determinations, and the prevailing offer exceeded the qualifying payment amount in about 87% of cases, according to CMS.
9. 11 times. When arbiters side with out-of-network providers, the average payout is 11 times Medicare rates, with some reaching 30 times, UnitedHealthcare said on its July 16 earnings call. Dan Kueter, CEO of UnitedHealthcare’s employer and individual business, said the IDR process “is not working” and needs reform. UnitedHealthcare told Becker’s it sees roughly 100,000 disputes a month.
10. 58. Fifty-eight employers and employer groups sent a letter July 10 to House Ways and Means Committee leaders opposing the No Surprises Act Enforcement Act, calling instead for “fixing the broken IDR system.” The bill, introduced by Rep. Gregory Murphy, MD, R-N.C., would raise penalties for plans and providers that miss payment deadlines after an IDR determination and has 36 bipartisan cosponsors. Three days later, the Coalition Against Surprise Medical Billing, which includes AHIP, launched a six-figure ad campaign against it.
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