What Happened?
If you've ever gotten a large, unexpected bill from a doctor who wasn't in your insurance network, you know how jarring that can be. The Congressional Research Service (CRS) found deep structural problems in the federal dispute resolution system designed to protect patients from shock medical bills.
The No Surprises Act (NSA), passed as part of a broader federal spending law in 2021, created federal protections against surprise medical bills from out-of-network providers. At its center is an Independent Dispute Resolution (IDR) process, where a private arbitrator decides how much an insurer must pay an out-of-network provider. The IDR entity selects between each side's payment offer.
Why Does it Matter to Me?
What happens in arbitration affects what you pay out of pocket, because your cost-sharing is tied to the Qualifying Payment Amount (QPA), generally an insurer's 2019 median in-network rate for a service, adjusted for inflation. Any change that raises the QPA directly increases what patients pay for out-of-network care.
Research found that some prices rose after arbitration, contrary to legislative expectations. Some physician practices also reported that health plans used the No Surprises Act to justify cutting or ending in-network contracts.
Both Sides, Now
Providers argue that insurers artificially suppress the QPA to tilt arbitration in their favor. Out-of-network providers or facilities prevailed in 85.7 percent of disputes from 2023 through 2025, according to a Congressional Research Service report.
Opponents of the current framework point to serious operational breakdowns. On Feb. 24, 2022, a federal judge threw out the rule giving the QPA a central role in arbitration, finding it legally defective, according to the Association of American Medical Colleges. On Aug. 25, 2023, federal IDR operations were temporarily suspended after another court ruling, according to Norton Rose Fulbright.
The Trump administration has extended enforcement discretion on QPA calculation methods, allowing insurers to keep using older approaches beyond their originally intended expiration date. Congress has not passed new legislation to address the backlog or the QPA dispute.
What Happens Next?
Federal agencies finalized a new IDR Operations rule on June 4, 2026, which took effect June 11. The rule cut the administrative fee from $115 to $15 per party per dispute, capped bundled billing line items at 50 per dispute, and required insurers to disclose the QPA during negotiations. Legis1 says that even these changes may not resolve the underlying tension over the qualifying payment amount.
Will the arbitration system deliver balanced results for patients and providers, or will the fight over the QPA keep driving costs and court battles?
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