NEWSROOM

Remember the No Surprises Act?

The No Surprises Act, enacted as part of the Consolidated Appropriations Act, 2021, took effect in 2022 and created federal protections against certain “surprise” out-of-network bills. It applies to emergency services, certain non-emergency services received at in-network facilities, and air ambulance services.

The law was designed for situations people actually encounter. In an emergency, nobody should be expected to stop and call the health plan to find an in-network emergency room before getting care. In most cases, the No Surprises Act protects a patient who receives emergency services from an out-of-network hospital or provider by limiting the patient’s financial responsibility to the applicable in-network cost-sharing amount.

It also addressed longstanding problems like receiving care at an in-network hospital but unknowingly being treated by an out-of-network anesthesiologist, radiologist, pathologist, or other provider. Some providers can use a notice-and-consent process to provide out-of-network services at an in-network facility in limited circumstances if a patient knowingly agrees in advance to give up the federal balance-billing protections. However, certain ancillary services – including anesthesiology – cannot use that process to waive the federal protections.

One notable exception: ground ambulance services are not protected under the federal No Surprises Act. Air ambulance services are protected, but federal law generally does not prevent an out-of-network ground ambulance provider from balance billing the patient.

California separately closed much of that gap through Assembly Bill (AB) 716, effective January 1, 2024, which provides balance-billing protections for ground ambulance services under California-regulated, fully insured plans. Those protections do not extend to self-funded plans. Nevada does not provide the same broad protection, and most states still do not have comparable ground-ambulance balance-billing protections.

So, who decides what the provider gets paid?

The patient may be protected from the “surprise” balance bill, but the provider and health plan still have to determine the payment amount.

Sometimes the two sides disagree.

That is where the federal Independent Dispute Resolution process (IDR) within the No Surprises Act comes into play.

The federal IDR process generally works like this:

1. The plan makes an initial payment – or denies payment. 
2. The provider and plan enter a 30-business-day open negotiation period to try to agree on the out-of-network payment amount. 
3. If they cannot agree, either side can initiate the federal IDR process. 
4. Each side submits the amount it believes should be paid, along with information supporting that offer, to a certified independent dispute resolution entity. 
5. The certified IDR entity selects between the two offers. It does not negotiate a new amount somewhere in the middle. The parties must then follow that decision. 

The important point for benefits professionals is that the patient is removed from that payment fight. The provider and health plan work through it behind the scenes.

Why are we talking about IDR again?

The IDR process is not new, but its use has grown far beyond what federal regulators originally anticipated.

CMS reports that more than 7 million disputes were initiated through the federal IDR portal between its launch in April 2022 and July 31, 2026. More than 2.1 million disputes were initiated during the first seven months of 2026 alone, including 394,140 in July. 

The process is still being adjusted, too. In May 2026, federal regulators finalized new rules intended to improve communication, clarify timelines, and streamline parts of the IDR process. 

At the same time, disputes between out-of-network providers and health plans have become much more visible. CMS data shows that providers, facilities, and air ambulance providers were the prevailing party in about 85% of federal IDR payment determinations during the second half of 2025, while plans and issuers prevailed in about 14%. 

Those numbers help explain why IDR keeps resurfacing in health care cost conversations, especially as IDR use continues to grow.

Is IDR contributing to higher premiums?

Possibly.

When the No Surprises Act was enacted, the Congressional Budget Office (CBO) estimated that it would reduce commercial health insurance premiums by roughly 1%. CBO expected the law to reduce what insurers paid providers in situations where surprise billing had been common, which could also lead to lower negotiated in-network prices.

But the IDR process has been used far more often than expected, and CBO now says the unexpectedly high use of IDR and the results coming out of the process could work in the other direction and contribute to higher premiums. CBO also says more research is needed before anyone can say exactly how much IDR is affecting costs. 

Health plans are also beginning to talk more publicly about the issue. UnitedHealthcare has been more direct. At an investor conference, its CFO recently said the company is “pricing for what we’re seeing out there” when it comes to IDR costs and said those costs are putting additional pressure on affordability. 

That does not mean IDR is the main or sole reason premiums are increasing. Health care costs are complicated, and IDR is only one piece of a much bigger picture. But with millions of disputes and providers prevailing in most determinations, it is reasonable to understand why health plans are paying closer attention to it.

Does an employer or broker need to do anything?

For most employers with fully insured health coverage – and the brokers who serve them – no new IDR task is landing on their desks. The carrier and provider handle this payment process behind the scenes.

Self-funded health plans are also subject to the No Surprises Act, but they have different responsibilities as the health plan itself, usually working through a TPA, ASO administrator, or other service provider. This is not intended to be a guide to administering IDR for a self-funded plan.

For most benefits professionals, the takeaway is awareness – not administration.
 

Bottom line

The federal IDR process has been around since the No Surprises Act took effect in 2022. What has changed is the scale.

Millions of disputes are now moving through the process, federal regulators are still refining how it works, and the results are becoming a bigger part of the conversation about health care costs.

Benefits professionals do not need to become IDR experts. But understanding what happens behind the scenes helps explain how the No Surprises Act protects members – and why a process that most brokers and employers never directly touch is getting so much attention.