More than four years after the No Surprises Act took effect, there has been significant public reporting on the independent dispute resolution process, as well as individual arbitration awards. But what happens after arbitration? As many independent physician practices are learning, many arbitration awards are going unpaid.
Under the federal Independent Dispute Resolution (IDR) process, providers and insurers can submit payment disputes to a certified third-party arbitrator when negotiations fail. Once an arbitrator issues a determination, the losing party is required to comply with the decision, and payment is due within 30 calendar days, according to the Centers for Medicare & Medicaid Services.
Across the country, hospitals and physician groups are discovering that winning an IDR arbitration is only half the battle. Two Colorado-based medical providers recently filed suit in Denver District Court alleging that Anthem Blue Cross and Blue Shield owes them a combined $2.1 million across 147 unpaid or underpaid IDR determinations. The providers’ attorneys characterized Anthem’s conduct as, “not isolated administrative errors” but rather “a pattern of retaining amounts owed while [providers bear] the financial burden of delivering care.” As of publication, Anthem has not publicly responded to the allegations in court filings.
Beyond unpaid IDR awards, there’s a broader dynamic at play: insurers have long relied on what’s known in the industry as the “float,” the pool of premium dollars and owed payments that insurers collect upfront, hold and invest before claims are paid out. Warren Buffett famously described float as “money we hold but don’t own” and has used it strategically to generate outsized investment returns. When an insurer delays a seven-figure arbitration award by 60, 90 or 180 days, providers claim that money doesn’t sit idle.
To put that incentive in context: Elevance Health, Anthem’s parent company, reported $197.6 billion in revenue for 2025, up 12.8% from $175.2 billion the year prior. Growth at that scale is not explained by improvements in care coordination alone, providers argue. The financial incentive to delay payments, even those mandated by a federal arbitration process, is embedded in the business model, said providers.
Meanwhile, providers operate on the opposite side of that ledger. Physicians and hospitals pay staff, maintain facilities, purchase supplies and deliver care immediately, often waiting months before reimbursement arrives. Every delayed arbitration award means more borrowing, more administrative overhead and less capacity to invest in patient care. As the Colorado providers put it in their filings, nonpayment has resulted in “the loss of funds necessary to operate a clinical practice, increased administrative and collection costs and the time-value loss of money that should have been paid when due.”
Compounding the problem: providers’ ability to fight back in federal court has narrowed significantly. In June 2025, the Fifth Circuit ruled in Guardian Flight v. Health Care Service Corp. that the No Surprises Act does not provide a private right of action, meaning providers cannot sue in federal court to enforce unpaid IDR awards. In January 2026, the Supreme Court declined to review the decision, leaving that ruling intact. Enforcement now runs largely through HHS’s administrative complaint processes, a path that has proven slower and less certain than federal litigation.
Independent physician groups are absorbing these financial shocks in an environment that already favors scale. A recent report from Avalere Health and the Physicians Advocacy Institute found that more than four in five U.S. physicians were employed by hospitals, health systems or corporate entities by the end of 2025, up 5.6 percentage points in just two years. Since 2024 alone, corporate entities acquired more than 8,000 physician practices, according to Becker’s ASC Review. A separate GAO report confirmed that at least 47% of physicians were consolidated with hospital systems in 2024, up from less than 30% in 2012.
An independent physician or hospitalist group carrying $2.1 million in unpaid arbitration awards, money they have legally won, faces a stark set of options: absorb the loss, borrow against it or sell. For many, the pressure to join a larger health system or accept a private equity acquisition is not a strategic choice. It is a financial survival calculation made easier when the alternative is chasing insurers through administrative processes for payments that were supposed to arrive 30 days after a neutral arbitrator’s decision.
What lawmakers didn’t anticipate is that, without real enforcement and with federal courts now largely closed off to providers, the 30-day payment deadline functions more as a suggestion than a mandate.
But individual lawsuits are expensive, slow and out of reach for every provider whose arbitration payment quietly stalls. Providers are calling for reform to create transparent payment tracking, escalating penalties for noncompliance. These reforms would go a long way toward ensuring that the law’s promise to providers is as real as its promise to patients.
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