A running log of regulatory, legal, and market developments affecting how the No Surprises Act plays out in practice.
This log is reviewed and added to periodically, not in real time — confirm anything time-sensitive against a primary source (CMS, DOL, or your counsel) before acting on it.
Energy and Commerce Committee Ranking Member Frank Pallone (D-NJ) sent oversight letters to six certified IDR entities — C2C Innovative Solutions, Commence, Dane Street, EdiPhy Advisors, National Medical Reviews, and ProPeer Resources — questioning whether arbitration is "functioning as Congress intended." Pallone cited winning offers that "far exceed commercial payment rates" and pointed to rising premiums, while also flagging IDR entities' lack of responsiveness to prior document requests. Separately, the bipartisan No Surprises Act Enforcement Act (H.R. 4710) remains pending before three House committees — Ways and Means, Education and Workforce, and Energy and Commerce — more than a year after introduction, with Ways and Means continuing its multi-year pattern of NSA implementation oversight. Together, these signal that Congress is actively weighing both stronger enforcement of IDR outcomes and closer scrutiny of the arbitrators making them.
A Health Affairs Forefront analysis from Georgetown's Center on Health Insurance Reforms (Jack Hoadley & Kennah Watts) estimates the federal IDR process generated $22.4 billion in total costs from 2022 through 2025 — $15.6 billion in payment awards above the QPA, $4.2 billion in estimated internal administrative costs, and $2.7 billion in IDR fees. 2025 alone accounted for $16.6 billion, roughly 3.5x the 2024 total, driven by dispute volume up 77% year-over-year and total award dollars up 264%. Providers continue to win about 85% of disputes, with a median 2025 award of 445% of QPA (up slightly from 447% in 2024, but with a much fatter tail: the 90th percentile jumped from 1,226% of QPA in 2024 to 1,771% in 2025). The piece names Radiology Partners, HaloMD, and TeamHealth as filing over three-quarters of resolved dispute lines in 2025, and reports early signs of IDR costs feeding into premiums — including one state employee plan citing IDR as a primary driver of a nearly 10% rate increase. See our IDR Statistics page for the detailed cost and award breakdowns.
A National Bureau of Economic Research working paper (Barwick, Li, Xia & Yu, “The No Surprises Act's Surprises,” NBER WP 35717, Sept. 2026) links federal IDR records to a national provider-network panel and ACA marketplace plan data. The authors find in-network participation fell after the NSA in the specialties and states most exposed to it — emergency medicine, anesthesiology, and radiology — the opposite of what a simple balance-billing-ban story would predict. They trace this to IDR itself: providers won about 86% of resolved disputes, with prevailing offers averaging roughly 10x the QPA, and network exit accelerated after a provider group's first favorable arbitration outcome. The paper also reports suggestive evidence that insurers more exposed to arbitration raised premiums faster. Worth a careful read for anyone pricing or reserving around IDR-driven cost volatility.
Sitting en banc, the U.S. Court of Appeals for the Fifth Circuit ruled that the Departments unlawfully let insurers include “ghost rates” — contracted rates for services a provider doesn't actually furnish — when calculating the Qualifying Payment Amount. The court held the NSA limits the QPA to rates for items “provided by a provider,” so placeholder or never-billed contract rates (which can sit at $0 or $1) must be excluded, not just zero-dollar ones. The court also held the Departments improperly let insurers exclude bonus, incentive, quality, and risk-sharing payments from the calculation, since the statute's “total maximum payment” language requires including them. It upheld one piece of the prior methodology — excluding certain one-off, single-case agreements, particularly for air ambulance — and a partial dissent argued the majority read the statute too narrowly on incentive payments. Practically: this is the third time TMA litigation has sent QPA methodology back to the drawing board (TMA I on the arbitrator presumption, TMA II on batching/methodology, now TMA III on ghost rates and incentive pay). Expect the Departments to lean on enforcement discretion while they revise the methodology, followed by new FAQ guidance — recalculating QPAs across the industry will not happen overnight, and QPAs are broadly expected to rise once it does.
CMS released the IDR Gateway Administrator User Guide (v1.0, Aug. 2026), introducing a new sign-in platform that will eventually replace the single-use web forms currently used to manage federal IDR disputes. Rollout is phased: in Phase 1, organizations that handle dispute processing — including TPAs managing disputes on behalf of clients — sign up and designate administrators; in Phase 2, additional staff join those organizations; in Phase 3, the federal IDR process fully transitions onto the platform and a Gateway account becomes required to submit web forms. Administrators will manage user roles (View Only, Initiation & Selection, or Full Access) and can set up "workspaces" to limit which staff see which disputes — useful for organizations handling disputes for multiple clients under separate inboxes. Organizations that only appear as a named party but rely on a TPA for day-to-day dispute handling should not create their own account — the TPA does.
The Departments issued “Federal Independent Dispute Resolution Operations” final rules, aimed at improving how the Federal IDR process actually runs — streamlining communication between payers, providers, and certified IDR entities and clarifying timelines and procedural steps. This builds on an October 2023 proposed rule targeting the same operational friction. CMS later published an implementation timeline guide for certified IDR entities and disputing parties (Aug. 7, 2026) to help both sides adjust their internal processes to the new rules.
Reps. Greg Murphy (R-NC), Kim Schrier (D-WA), John Joyce (R-PA), Jimmy Panetta (D-CA), Bob Onder (R-MO), and Raul Ruiz (D-CA), along with Sens. Roger Marshall (R-KS) and Michael Bennet (D-CO), introduced the No Surprises Act Enforcement Act (H.R. 4710 / S. 2420). The bill would amend the Public Health Service Act, ERISA, and the Internal Revenue Code to authorize penalties against any party — plan, issuer, or provider — that fails to comply with statutory payment timelines after a final, binding IDR determination, and would give federal regulators explicit authority to enforce those decisions. It responds to widespread reports that health plans simply aren't paying what IDR determinations say they owe. The AMA, joined by 50 state medical societies and 46 other healthcare groups, sent congressional leaders a letter of support in May 2026. As of this writing the bill remains in committee (House Ways and Means, Education and Workforce, and Energy and Commerce; Senate HELP) and has not been voted on.