No Surprises Act Arbitration Paid Providers $15 Billion Last Year. I Wouldn't Build a Budget on It.

CMS released its latest independent dispute resolution reports this week, and the numbers are the kind that make people on both sides of a negotiating table say "see, I told you."

Providers took nearly 1.4 million out-of-network billing disputes to arbitration in the back half of 2025. That's on top of roughly 1.2 million in the first half. Across the full year, providers collected somewhere close to $15 billion through the process, up from about $4.1 billion the year before.

That's not growth. That's a step change.

I've spent this week reading the reaction to those numbers, and almost all of it falls into one of two buckets. Payers say providers are abusing the system. Providers say payers force them into it by lowballing negotiations. Both of those arguments have real evidence behind them, and I'm not going to pretend I can settle them in a blog post.

What I want to talk about instead is the number nobody's building a plan around.

What actually happened in No Surprises Act arbitration in 2025?

Four things worth writing down.

Volume more than doubled year over year. About 2.6 million disputes were initiated across 2025, and the second half was busier than the first.

Payouts grew faster than volume. Roughly $15 billion in 2025 against $4.1 billion in 2024. Disputes went up by a bit more than half. Dollars went up by more than 3.5 times.

Providers win almost every time. In the fourth quarter of 2025, arbitrators made payment determinations in 532,548 disputes. In 462,973 of them, the amount awarded came in above the qualifying payment amount the insurer had proposed.

That's 87 percent.

Nearly half of all filings get challenged on eligibility. In both the third and fourth quarters, 42 percent of disputes were contested as ineligible for the process at all.

Who is actually filing these disputes?

This is the part that changes how you should read the other numbers.

The volume isn't spread evenly across thousands of hospitals and practices. It's concentrated in a handful of organizations. HaloMD initiated 19 percent of all disputes in both the third and fourth quarters. TeamHealth was second at 11 percent in both. SCP Health came in third, at 10 percent and then 7 percent. F&A Management and Radiology Partners rounded out the top five.

Five names. A meaningful share of a system built to handle disputes from every out-of-network provider in the country.

Some of those are physician staffing organizations with genuine out-of-network exposure. At least one is best described as a specialist that files disputes on behalf of others and takes a cut of what comes back. Payers have started calling that second category "IDR middlemen," and AHIP's spokesman used the phrase "gold rush" in a statement this week.

Insurers have also been losing in court. A Georgia court tossed a case an Elevance plan brought against HaloMD just last week, which continues a pattern that has not been going the payers' way.

Why are providers winning 87 percent of the time?

Because of how the process was built, and because of who chose to use it.

The qualifying payment amount, or QPA, is the insurer's calculation of the median contracted rate for a service in a geographic area. It's the number the payer brings into arbitration. Arbitrators are supposed to weigh it alongside other factors, including the provider's training and experience, the complexity of the service, and the parties' market share.

Courts have spent three years narrowing how much weight the QPA gets. Every time the QPA lost ground, the arbitration math tilted further toward the party bringing the dispute.

The other half of the answer is selection. If you only file the cases you expect to win, and you're a firm whose entire business is picking those cases, your win rate should be high. That isn't a scandal. It's what a specialist does.

But it does mean the 87 percent figure is describing something narrower than "providers are right and payers are wrong."

Is IDR worth it for a hospital revenue cycle team?

Right now, for a lot of organizations, honestly yes. There's real money moving through this process and it's going to providers.

I'd just be careful about what kind of money you think it is.

If you played Blockbuster's game, you already know how this goes. Late fees were a real revenue line. In the company's own SEC filings, extended viewing fees accounted for about 13 percent of domestic rental revenue in a single quarter of 2004, and eliminating them was projected to cost $400 to $450 million in revenue and $250 to $300 million in operating income for 2005. That's not a rounding error. People built forecasts on it. Nobody inside the company thought of it as a temporary artifact of a pricing structure that a competitor could make untenable.

Then it was gone. Not gradually. By decision, in one quarter, because the surrounding market changed and the policy stopped being defensible.

The money was always real. The durability was the thing nobody stress-tested.

An 87 percent win rate in an adversarial process isn't a competitive advantage. It's a signal that the process is mispriced. And mispricings in healthcare payment don't persist. They get corrected, usually by rulemaking, and usually faster than anyone budgeted for.

What's changing in the IDR process?

The correction has already started.

CMS finalized a rule in late May 2026 reforming the dispute resolution process, adding batch determinations and an online portal so providers can track dispute status. Provider groups welcomed it. Payers said it did nothing about what they call flooding behavior, which tells you the pressure hasn't been released.

Insurers are now asking regulators directly for structural changes to the incentives. They've been losing in court, which means the courthouse isn't the venue they'll keep choosing. When a well-funded industry stops winning lawsuits, it doesn't go home. It goes to the agency, and then to Congress.

I don't know what the fix looks like or when it lands. I do know that a 42 percent ineligibility challenge rate and a concentration of volume in five organizations is exactly the fact pattern that produces one.

What should a CFO do in the next two quarters?

Four things, in this order.

1. Find out what share of your out-of-network recovery is coming from IDR. Not the dollar figure. The percentage. If arbitration is producing more than a small slice of your out-of-network collections, you have a concentration exposure that belongs in your risk reporting, not just your cash reporting.

2. Look at your own ineligibility rate. If a meaningful share of your filings are getting kicked before they're heard, that's not a payer problem. That's your front end, and it's cheaper to fix than to litigate. Eligibility, benefit verification, and notice requirements are where those failures start.

3. Read your IDR vendor agreement, specifically the fee structure. If somebody is filing on your behalf for a percentage of recovery, understand that the incentive is volume, and volume is the exact behavior regulators are being asked to curb. I've argued across the RCM 2030 books that contingency fees are a symptom of an immature revenue cycle. This is the sharpest current example. A partner paid on a percentage of arbitration awards can't tell you what they did for your days in A/R or your patient experience, because those aren't what they're optimizing.

4. Take the leverage into contracting while you still have it. This is the one that matters in 2030. Every dispute you win is evidence about what your services are actually worth in your market. That evidence is more valuable inside a contract negotiation, where it produces predictable in-network revenue, than it is inside an arbitration queue, where it produces a check and another dispute next quarter.

The best possible outcome of the last three years isn't a bigger arbitration operation. It's a better contract.

The short version

The $15 billion is real. The growth rate isn't durable, the volume is concentrated in a handful of firms, nearly half of filings draw an eligibility challenge, and the losing side has stopped winning in court and started lobbying.

Use the process. Just don't confuse a payment mechanism with a payment strategy, and don't put a number in your 2027 forecast that depends on a rule nobody has agreed to keep.

Frequently asked questions

What is the No Surprises Act independent dispute resolution process? IDR is the federal arbitration process created by the No Surprises Act to settle payment disputes between out-of-network providers and health plans. After a required negotiation period, either party can initiate arbitration. Each side submits a proposed payment amount, and a certified arbitrator picks one of them.

What is the qualifying payment amount? The QPA is the insurer's calculation of the median contracted rate for a given service in a geographic area. It's the payer's anchor number in arbitration. Court decisions since 2022 have reduced how much weight arbitrators must give it relative to other factors.

How much did providers win through IDR in 2025? Roughly $15 billion across the year, according to CMS data reported in July 2026, compared with about $4.1 billion in 2024.

How often do providers win IDR disputes? In the fourth quarter of 2025, awards exceeded the insurer's proposed QPA in 462,973 of 532,548 determinations, or about 87 percent.

Why do so many IDR disputes get challenged as ineligible? Eligibility challenges ran at 42 percent in both the third and fourth quarters of 2025. Common causes include disputes over whether the service falls under the No Surprises Act, whether the required open negotiation period was properly completed, and whether state law governs instead of the federal process.

Is the IDR process going to change? CMS finalized reforms in May 2026 adding batch determinations and a tracking portal. Payer groups have publicly called for further action on what they describe as flawed incentives. Additional rulemaking is a reasonable expectation, though the timing and scope aren't settled.

April Wilson is the author of the RCM 2030 series, including RCM 2030: Strategy and Survival for Revenue Cycle Leaders and companion guides on operations, policy and regulation, and workforce modernization. She has 24 years of executive leadership experience and writes RCM 2030 Weekly, a Sunday briefing read by hospital CFOs and revenue cycle leaders.

Sources: CMS Federal IDR public use files and quarterly reports; Fierce Healthcare, "New CMS data spotlight continued rise in No Surprises Act disputes," Paige Minemyer, July 23, 2026; The Wall Street Journal reporting on 2025 IDR payouts; AHIP public statement, July 2026; Blockbuster Inc. Form 8-K filings, 2005.