By, Jack Hoadley, Kennah Watts, Katie Keith, and Ellie DeGarmo
More than five years ago, President Trump signed the No Surprises Act into law, newly protecting patients from some of the most pervasive types of surprise out-of-network bills. The law has successfully protected millions of consumers from the scourge of unexpected out-of-pocket costs. But implementation of the independent dispute resolution (IDR) process—i.e., the mechanism put in place by Congress for providers and payers to resolve disputes over out-of-network rates—has been plagued by high volume and high costs that could undermine the savings Congress expected when the No Surprises Act was enacted.
Building on our prior findings for IDR outcomes, this article offers an early look at publicly available IDR-related data from the first two quarters of 2025. Overall, the data show a significant uptick in the volume of IDR cases and corresponding administrative costs. This article also offers a brief update on recent developments in litigation over the No Surprises Act, which has contributed to a more costly IDR system. Indeed, many lawsuits in the most recent wave of litigation—in which payers are suing high-volume IDR middlemen and providers—reflect allegations that are consistent with the trends observed in the data below.
The Volume Of IDR Disputes (And Costs) Continues To Rise
As reported by the Centers for Medicare and Medicaid Services (CMS) in supplemental tables and public use files, the volume of cases submitted into the IDR process continues to exceed all expectations and grew rapidly in the first six months of 2025. During that period, parties submitted 1.2 million new disputes to the IDR portal—more than double the volume of the first two quarters of 2024 when nearly 590,000 disputes were filed. This amounts to a total of 3.4 million disputes from 2022 through June 2025.
And the number of disputes is only continuing to increase: Even more recent bi-monthly updates from CMS show that nearly 1.4 million cases were filed from July 2025 through December 2025. This has resulted in a whopping 4.8 million total cases through the end of 2025. As a reminder, federal officials expected approximately 17,000 disputes per year.
The ever-increasing volume of cases has contributed to higher administrative costs. IDR administrative costs include two fees for each dispute: an administrative fee and a fee paid to IDR entities, which are independent third-party arbitrators responsible for making payment determinations when providers and plans cannot reach an agreement on their own. In the first half of 2025, these fees totaled $844 million. This amount is staggering on its own. But it is even more alarming that this amount—for a six-month period—is nearly equivalent to the total of $885 million in administrative fees from 2022 to 2024.
The high fee amount in just six months suggests that IDR-related administrative costs are escalating quickly and that our prior estimate of $5 billion in total IDR-related costs through the end of 2024 will have risen substantially by the end of 2025. This would be true even before accounting for higher payment-related costs.
As volume continues to rise, IDR entities have grown more efficient. In the first six months of 2025, IDR entities—including three newly certified IDR entities—closed 155,000 more disputes than were filed. Despite this progress, a backlog remains with 430,000 disputes still outstanding as of late June 2025. The IDR process also continues to take more time than expected, with two-thirds of determinations exceeding the required 30-day period for resolution.
Large Provider Groups And Middlemen Continue To Prevail
Consistent with prior trends, providers continued to initiate (and win) the vast majority of disputes. In the first six months of 2025, providers and facilities initiated 99.9 percent of all disputes while plans initiated 0.01 percent. Of the provider-initiated disputes, 80 percent were submitted by providers while 20 percent were submitted by facilities. The bulk of these disputes were initiated against only a handful of insurers: more than half (57 percent) of all disputes were filed against UnitedHealthcare, Blue Cross Blue Shield of Texas (a subsidiary of the Health Care Service Corporation), and Aetna.
Four provider groups and provider representatives—mostly backed by private equity—initiated the majority of these disputes: HaloMD, Team Health, Radiology Partners, and SCP Health. HaloMD—a middleman organization that specializes in arbitration—initiated the most disputes, accounting for 17 percent of all disputes in the first quarter of 2025 and 22 percent of all disputes in the second quarter of 2025. For an organization that initiated a mere 1 percent of line-item claims in 2023, this is a rapid rise to prominence. The second most frequent initiator, Team Health, has long been a high-volume IDR participant and initiated 16 percent of all disputes in the first six months of 2025, a level that is consistent with prior years. Combined, the top four initiators accounted for more than half (56 percent) of disputes filed in the first two quarters of 2025.
Providers also won 88 percent of disputes—the highest provider win rate to date—as compared to 85 percent in 2024 and 81 percent in 2023. Radiology Partners prevailed most often, winning favorable IDR awards in 92 percent and 95 percent of its cases in the first two quarters of 2025, respectively. Team Health saw similar win rates of 94 percent across both quarters. HaloMD won slightly less often but still prevailed in 87 percent and 82 percent of its disputes in the first two quarters of 2025, respectively.
Ineligible Disputes And Default Decisions
Plans and providers continue to disagree about whether and which claims are eligible for the federal IDR system. In the first half of 2025, plans challenged 40 percent of cases as ineligible, similar to past years. The IDR entities deemed nearly a fifth (17 percent) of disputes ineligible, a slight reduction from prior quarters, which federal officials attribute to improvements to eligibility review processes. The persistence of ineligible disputes could result from miseducation or misaligned incentives for IDR entities, and federal officials acknowledge that ineligible disputes are “cluttering up the process.”
Beyond ineligible disputes, 22 percent of IDR determinations in the first six months of 2025 resulted from default decisions (i.e., where only one party submitted their offer and paid their fees). This is similar to the rate in earlier quarters. But it is concerning that more than one-fifth of determinations continue to be decided by default even after several years of IDR operations.
Plans Look To Relief From The Courts
Citing concerns about the volume of allegedly ineligible disputes and other IDR practices, plans have increasingly turned to the courts to sue IDR players. The first of these lawsuits was filed in December 2024, and more quickly followed. As of this writing, we are formally tracking nine such cases, and we are aware of several others—including, for instance, new lawsuits filed by UnitedHealthcare entities against IAS Arizona and Concord Company of Tennessee on January 30 and a new lawsuit filed by the Health Care Service Corporation against Neuromonitoring Associates on February 18.
Indeed, there are pending lawsuits against most of the entities that are responsible for initiating the majority of IDR disputes. This includes at least four lawsuits against HaloMD (in California, Georgia, Ohio, and Texas); at least one lawsuit against Radiology Partners (in Florida); and at least one lawsuit against SCP Health (in Virginia). These challenges have been filed by Aetna and Anthem/Blue Cross Blue Shield affiliates, among others. We are also aware of at least one shareholder lawsuit against a company for its alleged use of HaloMD as a vendor.
In general, plans assert that IDR middlemen and providers have “weaponized” the federal IDR system. How? By intentionally flooding the federal IDR system with claims that are not eligible for IDR under the No Surprises Act in an attempt to overwhelm the system, obtain default awards, and maximize reimbursement. The plans raise a variety of claims but generally allege that this conduct amounts to fraud, misrepresentation, and a violation of state and federal laws such as the federal Racketeer Influenced and Corrupt Organizations Act and the Employee Retirement Income Security Act.
Anthem, for example, sued HaloMD in California, alleging that more than half—55 percent—of HaloMD’s dispute submissions were ineligible for the IDR process and resulted in millions of dollars in improper payments to providers. HaloMD was able to file ineligible claims, Anthem alleges, by intentionally ignoring IDR system guardrails that were intended to prevent ineligible claims from being submitted. The complaint describes the federal IDR portal submission process in detail—screenshots and all—to allege that HaloMD knowingly made deliberate misrepresentations when submitting ineligible disputes through the IDR system.
Perhaps unsurprising given the volume of disputes we are seeing—and the dollars that are on the line—other stakeholders are engaging in the judicial process even when not a party to the lawsuit. In Anthem’s lawsuit against HaloMD, the California Medical Association filed an amicus brief in support of HaloMD while AHIP and a coalition of employer groups led by the American Benefits Council filed amicus briefs in support of Anthem. The latter brief explains that the continued widespread misuse of IDR will sharply increase costs for employers and employees.
As another example, Anthem Health Plans of Virginia sued SCP Health and others in November 2025. Anthem asserts that nearly 60 percent of the more than27,000 disputes defendants initiated against it since 2024 were ineligible for IDR under the No Surprises Act. For instance, of the 954 disputes submitted by SCP Health in a single day, Anthem alleges that 943 were ineligible for IDR. Even so, the plan lost 329 of these disputes and was ordered to pay an additional $340,000 in payments (over the original reimbursement) and $182,000 in administrative fees.
This complaint also highlights differences in outcomes between the federal IDR process and Virginia’s state-level IDR system. From May 2024 to May 2025, Virginia’s IDR system handled just 252 cases. In roughly that same time period, there were more than 34,000 Virginia cases filed in the federal IDR system according to CMS data. Furthermore, while providers prevailed in 85 percent of federal IDR disputes in 2024, providers prevailed in only 45 percent of IDR disputes when using Virginia’s IDR system (from May 2024 to May 2025). Anthem attributed these more balanced outcomes to explicit guardrails on Virginia’s IDR process and guidance from state officials.
Virginia is not alone in this experience. Most of the 10 states with state IDR systems where reports are available see far fewer cases than the federal IDR system. The one exception is Texas, where stakeholders initiated more than 500,000 cases in the most recent reporting year. Even there, most of these disputes—about two-thirds—were settled within the 30-day negotiation period prior to arbitration or mediation and thus did not proceed through the full IDR process.
More balanced IDR outcomes are also not unique to Virginia’s IDR system. State-level arbitration data show that providers win a majority of cases in most states but sometimes less frequently than in the federal system. For example, provider win rates were about 66 percent in New Jersey and about 60 percent in Washington but about 81 percent in New York. The experience in states across the country suggests that IDR can produce more balanced outcomes but that additional guardrails may be needed on the federal IDR system.
Providers Continue To Win High Award Amounts
Award amounts also continue to grow. CMS’s data includes the offer amounts from each party and the prevailing offer expressed as a percentage of the qualifying payment amount (QPA). The QPA is designed to represent the median in-network rate for each insurer and is used as the benchmark for reporting on payment determinations under the No Surprises Act.
For the first two quarters of 2025, Radiology Partners secured median awards of 582 percent and 594 percent of QPA, respectively. SCP Health won median awards of approximately 370 percent of QPA in both quarters, and Team Health won award amounts at a median of 277 percent of QPA. Of the top four initiating parties, HaloMD’s award amount far outpaced the others, with median payments of 920 percent and 835 percent of QPA in the first two quarters of 2025, respectively. To the extent that the QPA accurately represents median in-network rates, these results indicate that certain provider groups are receiving three to nine times in-network rates.
Even as providers secure high awards through IDR, providers have questioned the QPA’s accuracy in representing the in-network rate and challenged the federal government’s QPA methodology. All eyes remain on a lawsuit filed by the Texas Medical Association and LifeNet that is pending before the Fifth Circuit Court of Appeals. As discussed in more detail here, the full panel of Fifth Circuit judges is considering, among other issues, whether the QPA methodology improperly included so-called “ghost rates” and improperly excluded case-specific agreements for air ambulance services and bonus or incentive payments. Following oral argument in September 2025 and a request from the court, the parties submitted supplemental briefs on “ghost rates” in January 2026. A decision could be issued at any time.
If the Fifth Circuit allows changes to the QPA methodology, plans could face greater operational burdens in calculating the QPA. And, because the No Surprises Act requires cost sharing to be based on the QPA (or in some cases, on a rate determined under state law), any change that raises the QPA will lead to higher patient out-of-pocket costs for out-of-network care.
Providers Sue Over IDR Process And Awards
At the same time, and as discussed in more detail here, providers have begun suing plans over IDR awards. Indeed, we are tracking several lawsuits from providers who have sued plans to enforce IDR awards and obtain prompt payment. Providers have also accused payers of not fully disclosing information on the QPA as required under federal rules. In other instances, providers have accused IDR entities of improperly selecting the QPA as the appropriate offer. Some of these lawsuits involve alleged nonpayment of IDR awards to the tune of millions of dollars. And some providers regularly sue health plans over IDR awards of which, in some instances, the plan claims to have never received notice.
Although many lawsuits have been filed, providers cannot sue plans or IDR entities unless the No Surprises Act authorizes a private right of action. In almost every instance where this issue has been considered, courts have held that providers do not have such a right, including to enforce IDR awards. Most recently, the Supreme Court declined to hear Guardian Flight’s appeal of a Fifth Circuit decision that held that the air ambulance company did not have a private right of action to sue the Health Care Service Corporation over unpaid IDR awards. In November 2025, the Eleventh Circuit reached a similar conclusion, finding that judicial review of IDR awards under the No Surprises Act is limited to narrow exceptions, such as fraud.
Indeed, we are aware of only one instance where a district court has held that a limited private right of action exists under the No Surprises Act. In May 2025, a federal district court in Connecticut held that the No Surprises Act includes an implied private right of action that allows parties to ask a court to enforce IDR awards. This litigation is ongoing. Separately, a federal district court in New Jersey addressed judicial enforcement of IDR awards by denying a plaintiff provider’s motion to vacate an IDR award and granting the defendant plan’s cross-motion to confirm the IDR award. Each court emphasized that the final and binding nature of IDR awards meant that a court could enforce or confirm IDR awards, but the New Jersey court stopped short of finding a private right of action under the No Surprises Act.
In the absence of a private right of action, what is a provider to do? According to the courts, complain to CMS. These courts have directed providers to a provision of federal law that gives the agency the authority to enforce plan noncompliance with the law. Analysis of CMS reports shows that some providers have raised these concerns with the agency, filing nearly 1,600 complaints about late payments after IDR determinations through September 2024.
Where Do Things Go From Here?
The most recent IDR data from 2025 underscore continued concerns about rising volume and costs associated with the federal IDR system. As noted above, the volume of disputes for the first half of 2025 is nearly double the number of disputes from the first half of 2024—with administrative costs that, in only six months, are nearly as high as the total administrative costs from 2022 to 2024. We have no reason to think these trends will not continue but will learn more when CMS releases complete data from the second half of 2025. A full year of 2025 data will provide additional clarity on trends and help inform improvements to the IDR system.
Meanwhile, the Trump administration is poised to make its own changes to the IDR system. Federal officials are currently reviewing a draft final rule that would address stakeholder concerns related to the IDR process. The scope of the final rule is not known, but the Biden-era proposed rule included new restrictions on batched disputes and an overhaul of the eligibility review process. These changes could help address some of the concerns reflected above about the high volume of disputes and the submission of ineligible cases, in particular.
Finally, litigation over the No Surprises Act will undoubtedly continue. In addition to waiting on a decision from the Fifth Circuit on the QPA methodology, courts will continue to grapple with the question of whether providers (or plans) have a private right of action under the No Surprises Act. Even as plans newly take to the courts, any judicial relief will be delayed. These lawsuits take time, and we are not aware of a decision in a lawsuit initiated by a plan against providers and IDR middlemen.
Jack Hoadley, Kennah Watts, Katie Keith, and Ellie DeGarmo “The No Surprises Act IDR Process: An Early Look At 2025 Data” March 20, 2026, https://www.healthaffairs.org/content/forefront/no-surprises-act-idr-process-early-look-2025-data. Copyright © 2026 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.
