The No Surprises Act was intended to remove the threat of big “gotcha” bills from people who unsuspectingly went to an in-network hospital and were treated by an out-of-network specialist. That part has, largely, worked — patients are seldom at risk for this particular kind of surprise bill.
But one of the other intents of the bill, which took effect in 2022, was to attempt to address out-of-control costs in healthcare. That part is not necessarily working, experts say.
In a pair of articles in the magazine Health Affairs, researchers from the Center on Health Insurance Reforms at Georgetown University’s McCourt School of Public Policy analyzed data releases about the results of the bill and about the appeal process it set up, under which a provider is supposed to be paid and can then appeal the the payment amount from the insurance company via arbitration, called the Independent Dispute Resolution (I.D.R.) process.
What has happened, the researchers said, is that providers are challenging far more payouts than was originally anticipated — and those providers are overwhelmingly winning on appeal, collecting large sums of money.
3 to 4 times bigger
“When providers win, they typically receive fees that are three to four times the typical in-network rate,” two researchers, Jack Hoadley and Kennah Watts, wrote in one article about the arbitration process. “The high volume of I.D.R. disputes is generating significant spending from administrative costs and higher payments for services. This higher spending will likely be reflected in higher overall health costs and consumer premiums in the future. By estimating administrative and payment costs, and we find the I.D.R. process has generated at least $5 billion in total costs through the end of 2024.”
One notable fact, the two wrote, is the aggressive challenge strategy of firms backed by private equity — proving once again that private equity’s role in healthcare is serving to extract more money from the system at the expense of patients, or as we like to call them, people.
Their analysis of data “reveals that in 2023 and 2024, 43 percent of resolved line-item claims were filed by two private equity-backed provider organizations: Radiology Partners and affiliates (28 percent) and Team Health (15 percent). The top five provider organizations were responsible for 59 percent of line-item claims.”
Higher premiums
Chris Deacon of Versan Consulting, an analyst and consultant to the healthcare industry, took note of the developments in a LinkedIn post. The winners in the whole No Surprises saga are the providers and administrators, she wrote. The insurers will pass on their costs in the form of higher premiums, she added.
“Who pays in the end? Patients and employers through higher premiums.
“Meanwhile, patients are still blindsided — just in different ways.
“Good-faith estimates aren’t binding for the insured, and even for self-pay the protections are narrow and hard to use.
“Facility fees are slapped on routine visits as systems gobble up clinics.
“And when people try to ‘shop,’ hospital prices are missing, inconsistent, or wrong.
“The result: surprise bills still happen — only now they’re wrapped in compliance language.
Not a solution
“Bottom line: The N.S.A. stopped some egregious balance bills — but it did not solve ‘surprise billing.’ It shifted the venue from the mailbox to the arbitration portal and added toll booths along the way.
“What are some ways we would actually help patients and purchasers with surprise bills (and premiums):
“▪️ Make estimates meaningful for all patients; simplify and enforce the patient-provider dispute path.
“▪️ Curb nonclinical facility fees for off-campus, routine care.
“▪️ Fix I.D.R.: tighter eligibility screens, transparent benchmarks, and decisions anchored to real market data, not ‘who files best.’”
Legal challenges
In another Health Affairs article, Katie Keith, also of the Center for Health Insurance Reform, wrote an overview of the various legal challenges to the law.
“The more than 30 lawsuits on my radar have challenged the No Surprises Act itself; implementation of the law through federal rules and guidance; and actions by insurers, independent dispute resolution (IDR) entities, providers, and IDR middlemen,” Keith wrote. “This litigation has undeniably contributed to uncertainty and confusion for stakeholders, delays, and a more costly and high-volume federal IDR system that has undermined the savings Congress expected when the law was enacted. Most of the lawsuits, several of which date to as early as 2021, have been filed by or on behalf of the types of specialty providers that patients do not choose, including those backed by private equity firms, and where surprise billing and very high charges was the most common.
Insurers have begun to file aggressive lawsuits against providers like Radiology Partners and others like the third-party billers like HaloMD for filing large numbers of I.D.R. challenges.
“In May and June 2025, Blue Cross Blue Shield Healthcare Plan of Georgia (BCBSGA) and Community Insurance Company each sued HaloMD and providers in district courts in Georgia and Ohio, respectively,” Keith wrote. “HaloMD’s role in the I.D.R. process has grown exponentially. In 2023, HaloMD accounted for 1 percent of line-item claims; by the end of 2024, HaloMD was the fourth most active participant in the I.D.R. process.
“Both complaints allege that the defendants have engaged in a scheme to flood the I.D.R. process with ineligible disputes while making false representations of I.D.R. eligibility to federal officials, I.D.R. entities, and payers. For instance, BCBSGA asserts that HaloMD initiated 342 separate I.D.R. proceedings in a single day. Even though 279 of these disputes were ineligible, BCBSGA lost in 192 disputes and had to pay about $390,000 more to providers as well as nearly $119,000 in I.D.R. fees. Overall, BCBSGA alleges financial harm of nearly $6 million from these activities related to ineligible disputes.”
Blue Cross is accusing HaloMD of violating “the federal Racketeering Influenced and Corrupt Organizations Act (RICO), ERISA, state RICO laws, and state consumer protection laws in addition to allegations of fraud, among other claims.”
