Independent dispute resolution outcomes for planned procedures under the no surprises act

The No Surprises Act (NSA) protects commercially insured patients from balance bills. Providers win most disputes under the NSA's independent dispute resolution (IDR) process, with awarded payments (awards) several times in-network rates. While most disputes involve emergency care, awards for planned procedures may be even higher. This study quantifies awards from the NSA's IDR process for certain planned procedures (eg, plastic and spine surgery).

Using Elevance Health dispute data, this study compares awards from the 25 most common planned surgical and endoscopic procedures in 2024-2026 to the qualifying payment amount (QPA; defined by the NSA), in-network contracted rates (from transparency in coverage data), in-network Elevance Health claims, and Medicare prices.

The mean (median) cost of awards for disputed claim lines was $39 875 ($28 000), while the mean (median) QPA was $798 ($441). The median ratio of awards to benchmarks was 52.9 times the QPA, 53.4 times the median contracted rate, 28.5 times the median in-network paid claim, and 67.4 times the Medicare price. Providers won 89.4% of disputed claim lines, with little variation by provider or insurer offer.

IDR awards for certain planned procedures are extreme, with the median award exceeding 50 times the QPA.