Total costs associated wth the No Surprises Act's dispute resolution process reached $22.4 billion at the end of 2025, according to a new analysis.
Researchers at the Center on Health Insurance Reforms at Georgetown University’s McCourt School of Public Policy dove into the latest public data on independent dispute resolution (IDR) from the federal government, and found that of that $22.4 billion, $15.6 billion came from payments to providers that exceeded in network rates.
In addition, $4.2 billion came from administrative costs while $2.7 billion was attributed to fees and costs for the IDR entities, per the findings published Wednesday in Health Affairs.
Jack Hoadley, Ph.D., a research professor at CHIR and one of the study's authors, said during a briefing with reporters that there is data missing from the federal report, and likely internal administrative information that is not publicly reported but would play a role in costs, too.
"We actually think our estimate is conservative," he said.
Under the NSA, providers are barred from sending patients balance bills, or surprise bills, for certain out-of-network services. The process to resolve these claims has two phases: first, negotiation, and then if that fails, the parties move to IDR, a baseball-style arbitration decision.
The model was designed with the expectation that the majority of these claims would be resolved without the need for IDR, but trends haven't followed that intended pattern. The Georgetown researchers found that 2.6 million disputes were initiated in 2025, up 77% year-over-year.
That figure is still growing, too, per the study. About 1.75 million disputes have been filed through the first six months of 2026, according to the analysis, up 50% compared to the first half of 2025.
For comparison, the feds initially anticipated about 22,000 IDR cases per year.
The data also show that a small group of provider organizations and middlemen that file on their behalf account for large volumes of claims pushed to IDR, with three organizations accounting for nearly three-quarters of resolved disputes: Radiology Partners (30%); HaloMD (27%); and TeamHealth (20%).
Of note, both Radiology Partners and TeamHealth have private equity backing, the researchers said. HaloMD, meanwhile, is the largest of an emerging group of middlemen that support providers through the IDR process, and the company's share of resolved disputes jumped significantly between 2024 and 2025.
And the costs are escalating in tandem with a rising number of cases proceeding to IDR, the researchers found. Total awards from IDR grew by 264% between 2024 and 2025, and data suggest that the number of cases with payouts in the 90th percentile is increasing.
There are certain specialties where the researchers found that payments determined through IDR grew significantly in 2025 compared to the year prior. For example, the median award for emergency services was 315% of the qualifying payment amount, or QPA, that was brought to negotiation.
The median award paid out in neurology and plastic surgery doubled, the analysis found, ranging from payouts that were 24 to 30 times the QPA. The study used breast reductions as an example; median awards for this procedure were more than 80 times Medicare rates and accounted for $62.7 million in payments.
Part of what's driving that growth is that providers are far more likely to win when a claim reaches IDR. In 2025, providers won in 85% of cases, including a peak of 88% in Q2.
With the ongoing increase in both the number of IDR cases and the payouts, there have been calls for lawmakers to step in and adjust the No Surprises Act to mitigate these trends. The law also aimed to help tamp down rising healthcare costs, but increasing costs associated with IDR push against that goal.
"The enormous IDR cost inevitably will add to the insurance premiums paid by consumers, and we've already seen some employers and insurers attributing a portion of their premium increases to IDR costs," said Hoadley. "The time may, in fact, be ripe to revisit the NSA to realize the law's original cost containment goals without jeopardizing the consumer protections that are really the main reason this law got passed in the first place."