Several recent articles argued that the No Surprises Act (NSA) is broken. These articles point to the high percentage of Independent Dispute Resolution (IDR) wins for providers and award amounts far above the Qualified Payment Amount (QPA). At first glance, those statistics may look concerning. A closer look shows a very different picture.
Provider success in IDR is not proof that the system is flawed. It reflects the fact that the QPA is set artificially low. When QPA calculations include “ghost rates”—contracted rates for services never actually provided—the benchmark gets pulled below Medicare levels. Shortly, the Fifth Circuit will once again rule on the method for calculating the QPA and whether ghost rates are permissible. For now, if insurers base their offers on these depressed QPA amounts, it is no wonder that arbitrator’s side with providers.
The broader impact of IDR on healthcare costs is also small. Even using a conservative estimate where all 2024 fourth-quarter disputes were awarded at four times the median QPA, the total annualized awards represent a small fraction of charges under commercial plans. Out-of-network care accounts for only a small slice of total spending, and studies of 312 ACA exchange markets found no evidence that the NSA is driving premium increases. In fact, none of the carriers mentioned the NSA as a factor in rising policy costs. That silence speaks volumes: if the Act were inflating premiums, insurers would certainly point to it in their filings. Instead, with QPA amounts depressed below Medicare and more than 70% of estimated eligible claims for IDR not being submitted, payors are experiencing a large windfall from implementation of the NSA.
It is also important to remember the primary goal of the NSA. Patients are now protected from surprise medical bills, their cost-sharing is capped at in-network levels, and payments count toward their deductibles and out-of-pocket limits. This protection has reduced financial stress and allowed more people to obtain care they might otherwise have skipped from the best of providers.
There are still challenges. Some payors delay paying awards, making meritless eligibility challenges. Indeed, the IDR process continues to evolve with additional regulations expected in late 2025. These are real frustrations, but they are administrative problems, not evidence that the law itself is broken. This is further evidenced by recent announcement from the House Ways and Means Committee in fully supporting the ongoing implementation of the NSA. https://waysandmeans.house.gov/wp-content/uploads/2025/09/WM-NSA-Letter-2025-FINAL.pdf.
The NSA is working as it was written as patients are better off. Further regulatory implementation of the NSA is needed to continue to protect patients and enforce compliance with the NSA requirements.