No Surprises Act arbitration databook

The No Surprises Act (NSA) established a final-offer arbitration process called independent dispute resolution (IDR) to settle payment disputes between health insurers and health care providers for certain out-of-network services.

This webpage provides data on how the IDR process is working, including estimates of the average prices emerging from IDR, qualifying payment amounts (QPAs) calculated by health plans, and comparisons of plan and provider offers, all expressed as percentages of Medicare’s payment rates for the same services. It also includes information on the characteristics of the providers and firms using the IDR process.

These estimates use dispute-level data published quarterly by the Centers for Medicare and Medicaid Services (CMS). We anticipate updating this page annually as complete calendar-year data become available. Details on our analytic methods, which are largely adapted from prior analyses of the data CMS released for 2023, are provided at the bottom of this page.

Methods

This section describes the methodology underlying each set of estimates published above.

Figure 1-4

The estimates reported for the first and second half of 2023 were obtained directly from analyses of CMS IDR data that two of us (Adler and Fiedler) published for the first half and second half of 2023. For 2024, we calculated the reported estimates by applying the methodology used in the analysis for the second half of 2023 to the 2024 data.

Figure 5, Table 1, and Figure 6

For these exhibits, we used the methods described in the published analysis for the second half of 2023 to define the sample of line items for each service type, calculate Medicare ratios, and “trim” the sample to account for the presence of facility services in the IDR data. Additional details pertaining to each exhibit follow.

Figure 5

We limited the sample to line items where both the QPA and decision are reported. We then tabulated the share of line items with Medicare ratios in each bin.

Table 1

To determine which line items list email domains that are associated with revenue-cycle management (RCM) vendors or vendors that handle IDR disputes on providers’ behalf, we first identified all email domains that appeared on at least 200 line items in our sample. We manually reviewed those email domains and used public sources to determine whether the domains are associated with RCM or IDR vendors. This procedure revealed that the following RCM and IDR vendors are present in the IDR data: HaloMD, AGS Health, R1, Ventra Health, QMACS, Zotec Partners, LogixHealth, SimplexMed, MD Capital Solutions, and PracticeMax. A limitation  of our approach is that it will not identify instances where a practice relied on an RCM or IDR vendor to handle some aspects of the IDR process but listed its own email address when submitting the dispute to IDR. Thus, our estimates may understate the role of RCM and IDR vendors in the IDR process.

Figure 6

We assigned line items to parent companies as follows. We also present the share of line items identified after each step using the 2024 data.   

In a first step, we identified all email domains that appeared on at least 200 line items. Such domains accounted for 99.8% of line items. We manually reviewed each such domain and used Pitchbook, press reports, and other public sources to determine whether the email domain corresponds to a physician practice or a firm that owns physician practices and, if so, to assign it to the appropriate parent company. Via this email domain review, we were able to attach parent information to 82.6% of line items in our sample.

A limitation of this approach is that it does not assign parent companies to line items where the email domain corresponds to an RCM or IDR vendor, is below the 200-line-item threshold, or is missing. To address this issue, we used the national provider identifiers (NPIs) reported on each line item. For 90% of line items in our sample, the reported NPIs are Type 2 (organizational) NPIs, which correspond to physician groups rather than individual clinicians. We matched these NPIs to the National Plan and Provider Enumeration System to obtain the authorized official for the NPI. Importantly, authorized officials are frequently shared across practices that are part of the same firm.

We then used this information in two ways. First, where some line items associated with an authorized official had been assigned a parent company based on email domain, but others had not been, we assigned the same parent company to the unclassified line items. After this step, 94.0% of line items in our sample had been assigned parent information. 

Second, where an authorized official appeared on at least 200 line items that remained unclassified after this step, we manually reviewed the provider names listed in the IDR file for the associated line items to identify the parent company. This process helped to identify groups that relied heavily on RCMs or an IDR vendor such as Surepoint Medical Center, IES Healthcare, Physicians Premier ER, American Physician Partners, Pediatrix, and Concord Medical Group, among others. After all of these steps, 97.9% of line items in our sample had been assigned parent information.

The figure classifies parent companies into three categories: (1) publicly traded; (2) private-equity-affiliated; and (3) other parent. We placed a company in the first category if it is currently publicly traded. We placed a company in the second category if it is currently owned by private equity investors or had been owned by private equity investors prior to bankruptcy or restructuring. All other parents were placed in the final category.