An Analysis of No Surprises Act (NSA) Independent Dispute Resolution (IDR) Emergency Service Outcomes Relative to In-Network Rates

The No Surprises Act (NSA), part of the Consolidated Appropriations Act, 2021 (P.L. 116-260), established various consumer protections related to surprise billing—that is, circumstances in which individuals receive large, unexpected medical bills when they are unknowingly, and potentially unavoidably, treated by out-of-network (OON) providers. The NSA also specifies a methodology to be used to determine how much insurers must pay OON providers for care in specified situations. Under the federal payment methodology, when an insurer and an OON provider cannot agree on the relevant payment amount, either party may initiate an independent dispute resolution (IDR) process before a private arbitrator. In a process commonly described as “baseball-style” arbitration, the insurer and provider each submit to the IDR entity an amount representing what the party believes the total price of care should be (i.e., a payment offer), and the IDR entity then selects between the parties’ payment offers. Since the IDR process became operational in April 2022 and through 2024, its utilization has exceeded initial expectations, with over 2 million initiated disputes. Providers have initiated nearly all disputes, and have been very successful in the IDR process; in 2023 and 2024, the IDR entity selected the provider’s offer in approximately 80% and 85%, respectively, of the disputes that resulted in a payment determination. Emergency service disputes represent the most common type of dispute. The median prevailing offers for emergency service disputes ranged from 2½ to 3 times the qualifying payment amount (QPA) in 2023 and 2024. The QPA is a statutory benchmark defined as an insurer’s 2019 median in-network rate for a particular item or service furnished by a provider in the same/similar specialty and location, indexed for inflation. The QPA is a significant part of the IDR process and has been a focus of interest groups during NSA implementation. Providers have expressed concern about the lack of QPA transparency and have asserted that insurers are incorrectly determining the QPA. Insurers have indicated that the QPA represents the market rate for services. Outcomes from the IDR process affect health care costs through payments that insurers make to providers for OON care and can affect subsequent negotiation of in-network rates between insurers and providers. The Congressional Research Service (CRS) analyzed IDR process emergency service outcomes in 14 states against the in-network rates of IDR-participating providers to compare QPAs, insurer and provider offers, and prevailing offers. For IDR emergency service disputes determined in the first half of 2024, (1) over 95% of disputes had a prevailing offer that was above the 2025 median in-network rate among IDR-participating providers, and (2) the median prevailing offer in the IDR process for emergency service was over three times the 2025 median in-network rate among IDR-participating providers. In addition, (3) the median QPA was slightly higher than the 2025 median in-network rate of IDR-participating providers. Further analysis by state highlights that (1) in all 14 states assessed, the median prevailing offer for emergency service disputes determined in the first half of 2024 was greater than the 2025 median in-network rate of IDR-participating providers; however, (2) the degree to which the median prevailing offer exceeded the median in-network rate of IDR-participating providers varied by state. In Nevada and California, the median prevailing offer was slightly higher than the median in-network rate, whereas Colorado saw a median prevailing offer that was over six times the median in-network rate of Colorado IDR-participating providers. In total, nine states had a median prevailing offer that was more than three times the median in-network rate. Additionally, (3) the relationship between the QPA and median in-network rates varied across states. In six states, the median QPA was less than the median in-network rate; in eight states, it was greater than the median in-network rate.