As a member of the Coalition Against Surprise Medical Billing, Katy Spangler helped push for the No Surprises Act in 2020. However, on Wednesday, she took the stage at the AHIP Medicare, Medicaid, Duals & Commercial Markets Forum to call for changes to the law.
The No Surprises Act protects patients from unexpected bills and removes them from insurer-provider payment friction. The act requires insurers and providers to enter into 30 days of open negotiation to determine how much providers are paid. If they can’t come to an agreement, either side can use the Independent Dispute Resolution (IDR) process, in which a provider submits a payment offer and an insurer submits a payment offer and then a neutral arbitrator (called an IDR entity) picks one.
While the act is successful in protecting patients against surprise bills, Spangler and others in the industry are arguing that the IDR process is now being abused by some providers. What was meant to be a last resort has instead seen an explosion in volume, with providers initiating the vast majority of IDR cases and winning most of the time at significantly inflated award levels, she said.
“When we have an in-network surgeon who has agreed to $800 for the reimbursement for that surgery, but an assistant surgeon takes that same case to IDR, and they get $80,000, that is unsustainable. … This is crazy — we have got to fix this problem,” Spangler said on the panel.
Recently published data from another panelist backs this up. Kennah Watts, a research fellow at the Center on Health Insurance Reforms (CHIR) at Georgetown University’s McCourt School of Public Policy, explained on the panel that there have been 3.4 million IDR disputes from 2022 through June 2025. CMS, however, anticipated there to be about 55,000 over that same time period.
Watts added that providers and healthcare facilities are initiating 99% of disputes.
“We also see that not only are providers submitting the vast majority of disputes, but they’re winning a majority as well, and they’re winning at much higher rates than plans. … We can see that to date, [when providers] win, they have a median win rate that’s about 4.5 times the in-network rate,” she said.
And the IDR process is costly: from 2022 to 2024, the IDR process has incurred about $5 billion in total costs, according to Watts’ data.
A health insurance executive on the panel — Josh Goldberg, executive director of health policy at Health Care Service Corporation — echoed these issues. He noted that the company has seen about 750,000 IDR disputes and keeping up has been extremely challenging.
“Between two months, you might see a swing of 40% in terms of volume and so accurately staffing for that fluctuating volume is very difficult,” he said. “We see, I think, what may be intentional manipulation of the volume to try and concentrate a lot of volume in a short period of time to make the response more difficult. … Currently, we have well over 400 people just working IDR disputes. That’s significant. Those salaries, the cost of that all has to be paid somewhere, and it comes out in premiums.”
He added that because of the volume of IDR disputes, he doesn’t think IDR entities are able to give the disputes adequate consideration. He noted that a $7,000 claim for a respiratory panel resulted in a $255 million award through the IDR process.
“Now, to their credit, we went back to the IDR institute and said, ‘You want to look and see if there’s a mistake here, because this can’t be right.’ They acknowledged that they had an error, selected the wrong prevailing party, and they went to CMS and had that reopened,” Goldberg said. “But I think it’s indicative of the stress that they are under to close cases very quickly, and that results, I think, in a reduction in the quality of work that they’re able to do.”
As for how to improve the IDR process, Spangler argued that the current administration should take regulatory action to block ineligible claims from entering arbitration and address flawed incentives that encourage improper IDR rulings. However, congressional action may be needed as well.
“There’s a lot that we think can happen to make this less bad, but it’s really bad, and I’m so sad to say it,” Spangler said.
Photo: KLH49, Getty Images
