No Surprises Act: Insurers Point the Finger. The Facts Point Back.

Physicians nationwide are already stretched thin – managing workforce shortages, rising practice costs, and crushing administrative burdens – while working to keep their doors open and care for patients. Increasingly, they are fronting the cost of care and then navigating the federal arbitration system just to be paid fairly.

And yet, insurers like Elevance Health are now claiming that the very system designed to protect patients, such as the No Surprises Act (NSA) and its Independent Dispute Resolution (IDR) process, is driving costs, being misused by providers, and operating outside its intended purpose.

That narrative might be convenient for Elevance – one of the country’s largest insurers – but it does more to protect its profits than reflect the facts.

The NSA is doing exactly what Congress intended: protecting patients from surprise medical bills and removing them from the middle of payment disputes. The real problem is not the law itself; it is how its implementation allows insurers to operate within it.

IDR is Not Driving Healthcare Costs

The claim that IDR is driving healthcare costs is not just overstated, it misdiagnoses the problem entirely. Healthcare costs in the U.S. are undeniably high and continue to rise, driven by a range of well-documented factors. But the NSA and its IDR process are not among them.

IDR represents only a tiny fraction of the $4.9 trillion in annual national health spending. More importantly, these are not new costs introduced by the law. They are costs that previously landed directly on patients in the form of surprise medical bills. The NSA did not create these expenses. It simply ensured patients are no longer the ones forced to absorb them.

Without the NSA and IDR process, patients would once again be caught in the middle, facing unexpected medical bills on top of already rising prescription drug prices and insurance premiums. Shifting financial responsibility away from patients and into a structured dispute process is not a cost driver. It’s a patient protection.

Elevance Health reported nearly $198 billion in revenue and $5.7 billion in profit in 2025, while returning billions to shareholders. Against that backdrop, claims that IDR is driving unsustainable costs are hard to take seriously. This is not about financial strain. It is about who gets paid and how much.

High Volume Reflects Underpayment and Broken Implementation

Insurers often spread misinformation about IDR volume, and specifically so-called “ineligible claims,” as evidence that providers are flooding the system, ignoring both the law’s structure and how the system actually functions.

The NSA IDR process is narrowly defined. It applies only to emergency services, post-stabilization care. and certain non-emergency services provided at in-network facilities. For scheduled services, providers are required to give advance good-faith estimates, and the law allows patients to waive protections only under strict notice-and-consent rules. In other words, the vast majority of routine, office-based care is prospectively managed and never enters the IDR system in the first place.

So if disputes are showing up in volume, it is not because providers are indiscriminately sending in every claim. It is because insurers are underpaying, denying, or mishandling qualified claims on the front end, forcing providers into IDR to receive fair and sustainable reimbursements.

At the same time, the scale of the system was dramatically underestimated. Federal agencies estimated 17,000 disputes annually. In reality, the system saw 489,000 disputes in its first 14.5 months. This is because the agencies lazily built a model on flawed assumptions, largely focusing on the experience of New York’s unique system that limits disputes in ways the federal law does not.

Taken together, the story is clear: high volume, including disputes later deemed ineligible, is not evidence of providers gaming the system. It is the predictable outcome of underpayment, inconsistent implementation, and a process that was never designed for the scale it now faces.

Providers Scrupulously Adhere to the System, Insurers Don’t

Another common claim is that third-party actors are flooding the system and driving up disputes. In reality, these entities – companies built to help doctors manage this paperwork problem – exist because the system demands it. Physicians are already operating under immense pressure and do not have the time or administrative capacity to manage the federal arbitration process on their own.

Third-party entities help providers navigate compliance requirements and pursue fair reimbursement for care that has already been delivered. They do not and cannot determine outcomes. Rather, independent, qualified and certified arbiters, called IDREs, do.

Under the NSA, insurers are required to pay IDR awards within 30 days. Yet physicians across the country report that this requirement is frequently ignored. As the American Medical Association noted in a letter to Congress, many physicians are not receiving payment within the statutory time frame, and some report receiving no payment at all. These delays are not minor administrative issues – they threaten the stability of medical practices and, ultimately, patients access to reliable care. See here, too, for a new letter from the American Medical Association and 111 other medical organizations to the Departments of Health and Human Services, Treasury, and Labor explaining how health insurers are increasingly undermining the No Surprises Act.

The Real Problem: Insurer-Controlled Benchmarks

At the center of many disputes, and the factor skewing most policy analysis and commentary, is the Qualifying Payment Amount (QPA), which insurers often present as an objective benchmark.

It is not.

Congress intended the QPA to reflect an insurer’s median in-network rate. In practice, it is a black box calculated by insurers and shielded from meaningful scrutiny. Instead of reflecting real market rates, QPAs are often used to justify payment offers that bear little resemblance to the cost of delivering care.

The data is clear. In more than 60 percent of IDR disputes studied, the QPA was lower than the median in-network rate, with actual rates averaging roughly three times higher. In some cases, QPAs are reported at just a few dollars, or even less, paired with payment offers of $0.

This also helps explain dispute volume. When insurers anchor payments to artificially low QPAs, they create the very disputes they later point to as a problem. Blaming providers for using IDR in that environment misses the point.

When IDR awards exceed the QPA, that is not evidence of overpayment. It is evidence that the benchmark itself is flawed. Independent arbiters are doing what the law requires – reaching fair, market-based conclusions rather than deferring to insurer-contrived numbers.

The Law is Working for Patients

Despite these challenges, the broader data show that the NSA is working. A recent Government Accountability Office (GAO) report found that the law is reducing surprise medical bills and encouraging more care to be delivered in-network. These are clear indicators that the law is delivering on its core promise to patients.

There is no question that the IDR process can be improved. But the solution is not to weaken the law or shift blame onto providers. It is to fix the implementation and enforce the rules that already exist. That means ensuring health insurers pay arbitration awards within the required 30-day time frame, correcting QPA calculations so they reflect actual market rates, and addressing operational failures within the IDR system.

The NSA took patients out of the middle. That was a major step forward. Now the focus should be on making sure the system works as intended for everyone else, starting with holding insurers accountable to the law they claim to support.