Who Benefits from $5B Generated by IDR Arbitration?

The arbitration process established by the No Surprises Act has generated $5 billion in costs and significant operational challenges, yet a handful of providers are winning substantial financial awards.

The independent dispute resolution (IDR) system, established by the 2020 No Surprises Act (NSA), has overwhelmed regulators with volume and driven significant revenue for some providers, according to an analysis published in Health Affairs.

From 2022 to 2024, the federal arbitration process has generated $5 billion in total costs that will likely impact overall healthcare spending and patient premiums.

A breakdown of total costs estimates:

• $2.24 billion in payment amounts to providers
• $1.9 billion in internal costs for payers and providers
• $656 million in IDR entity fees
• $228 million in administrative fees

Despite the added costs and administrative burden, providers are likely coming out on top. IDR favored providers on 85% of line-item claims in 2024 and 81% in 2023.

However, the big winners are concentrated among a small group of providers. Just five organizations were responsible for 58% of claims between 2023 and 2024. Additionally, 63% of all closed line-item claims came from just four states: Arizona, Florida, Tennessee, and Texas.

A higher-than-expected volume of disputes has overwhelmed the government-approved third-party entities responsible for administering arbitration. Estimates suggested that IDR would handle a little more than 22,000 disputes annually, but more than 3 million disputes were filed between mid-2022 and May 2025.

Median days to determination fell to 81 days at the end of 2024, down from a peak of 96. While determinations are being made in a timelier manner, the volume has made it difficult for arbitrators to meet the 30-day statutory deadline and led to a backlog of nearly 500,000 cases.

The slow pace of the IDR process has caused frustration for providers wanting to improve cash flow.

"At the outset, we really didn't how (IDR) would work," Amanda Bessicks, executive director of government and vendor relations at Baptist Health in Northeast Florida, told HealthLeaders. "We now have a good understanding of how the IDR process works, but it's a very, very slow process, and so you're not getting claims resolved very quickly."

The high costs and the concentration of benefits among a small group of providers have led some to question whether IDR is sustainable long-term. However, there is clearly financial gain to be had for revenue cycle leaders who can manage the administrative burden and invest in an aggressive IDR strategy.