The No Surprises Act is the most important piece of legislation for providers that most have never heard about. After years of patient complaints regarding balance billing, the NSA was launched Jan. 1, 2022, to protect patients and their rights with out-of-network care. Providers win the majority of NSA disputes, while most of that money still goes uncollected due to the complicated nature of the submission and collection process. In 2025, providers prevailed in roughly 86% of the payment determinations issued through the federal NSA independent dispute resolution process — across about 2.23 million determinations. In roughly 87% of those, the award exceeded the plan’s qualifying payment amount. That number continues to grow each month.
Although providers win the majority of NSA out-of-network claims, much out-of-network money is still uncollected because most practices either do not file at all or hand it over to a contingency firm that keeps 20% to 25% of the payment. In my experience, most providers start with a contingency firm, and some move the work internally once they see how often providers prevail — managing it at a lower cost and with greater efficiency.
Providers need to know their winning percentage if the claims are processed outside of the practice. Use the federal numbers as a benchmark rather than a pass/fail line. The published rate is a share of payment determinations, not of claims filed — in 2025, about 2.80 million disputes were closed but only 2.23 million reached a determination, with most of the rest closed on eligibility. Filing volume is also dominated by a handful of high-volume radiology, emergency medicine and anesthesia billing companies, so the aggregate rate reflects their case mix. If your own rate sits well below it, look first at eligibility screening and deadlines before you blame the claim.
In practice, it fails in four common places:
- Deadlines. The greatest frustration is missing the open negotiation window — which starts on the date of the initial payment or notice of denial — because that eliminates the claim from the arbitration process. IDR is a chain of short, unforgiving windows — 30 business days of open negotiation, then four business days to initiate, then 10 business days after the certified IDR entity is selected to submit your offer. Miss one and the claim is forfeited by default. This is the most common and most avoidable way practices lose. The windows are also about to change: under the 2026 final rule, open negotiation must be initiated through the federal IDR portal with the notice attached to the remittance or denial, and the non-initiating party must respond by the 15th business day. That becomes applicable 90 calendar days after the departments announce portal functionality; IDR gateway account creation opened Sept. 15, 2026.
- The QPA anchor. The plan’s opening payment is tied to its qualifying payment amount — a median contracted rate that usually sits below the fair value of the service. Treat the QPA as the floor, not the ceiling — accepting it is accepting underpayment. Build your offer above it and document why.
- The offer. IDR is final-offer arbitration where each side submits one payment number and the arbiter picks one or the other. The payment amount and the case built for it — provider training and experience, patient acuity and case complexity, market share, and good-faith contracting efforts — are the whole dispute. Note what the arbiter may not consider: your usual and customary charges, and public payer rates. A bare number loses to a payer who did the homework.
- Payment. Following up for payment on won claims is a full-court press. No one cares about the payment more than the provider, and someone needs to constantly badger the insurance companies for payment.
Deadlines and final payment are the two greatest pain points, and they are the parts contingency firms and revenue cycle companies are not built to chase. Processing the IDR claim is actually the easy part and requires knowing winning and default rates by payer and by code through a disciplined operation. Most practices have neither, so they do not file — or they simply outsource to an outside firm.
The 2026–2027 policy changes bring three shifts that make engaging with IDR a stronger move than it has ever been:
- The fee collapsed. For disputes initiated on or after June 11, 2026, the administrative fee dropped from $115 to $15 per party. But the administrative fee was never the main cost. The certified IDR entity fee still runs $200–$840 for a single determination and $268 to $1,173 for a batched one; both parties pay it up front, the nonprevailing party eats the fee, while the winner’s fee is refunded. The real math is that fee spread across up to 50 line items — plus the refund when you win. That is what makes the mid-size denials you used to write off pencil out.
- Batching is real. For disputes whose open negotiation period begins on or after Nov. 1, 2026, up to 50 qualified IDR line items can go into a single dispute. The criteria are specific: the same plan and the same or similar items or services furnished within a 30-business-day period, the same patient on consecutive dates, or related specialty services — anesthesiology, radiology, pathology and laboratory. If the same payer underpays the same code repeatedly, the per-claim cost and effort fall through the floor.
- Transparency is coming. For services on or after Jan. 1, 2027, payers must attach standardized claim adjustment reason code/remittance advice remark codes and their IDR registration number to remittances sent to out-of-network providers, along with the plan’s legal business name, plan sponsor information, and a statement on initiating open negotiation — easier to substantiate, harder to obscure. These codes help providers identify which patients are eligible for the NSA and can be obtained electronically, reducing processing time.
Who is processing the claims?
In my experience, most practices billing out-of-network use a contingency firm charging 20% to 25% of collected revenue, followed by revenue cycle companies, with only a small minority handled internally by the providers themselves. There is no public dataset on that split. The reason most providers are not bringing the process in-house is fear of losing arbitrations during their conversion window, or losing outright. Contingency firms and revenue cycle companies are not always the wrong choice; for a practice with no bandwidth, it can make the most sense. But most groups default to it without ever running the numbers, and the 2026–2027 changes make that default more expensive relative to owning the work.
Where technology changes the math
The reason IDR historically required a dedicated team — or a contingency firm — is that the disciplined process is data-intensive: screening every claim for eligibility, knowing your win and default rates by payer and CPT, tracking each deadline, and justifying an offer against millions of prior determinations. Those are exactly the tasks AI now handles well. Software can flag which claims qualify, surface your own win rates against a given payer, watch the calendar, and assemble a defensible offer from the federal and state determination record — turning what used to demand headcount into something a practice can run in-house. AI doesn’t win the arbitration for you; it removes the operational friction that kept most groups from filing at all.
What to do this year
- Measure your win and default rates by payer and CPT. Across the federal program, providers prevail in roughly 86% of payment determinations — a useful benchmark, though your own mix of payers and codes will drive your number.
- Screen eligibility before filing. Wasted fees on ineligible disputes poison the whole effort. Know what qualifies for federal IDR versus a state process.
- Never miss a deadline. Track every window. This one discipline outperforms any clever argument.
The No Surprises Act stopped patients from being caught in out-of-network payment fights. It also, quietly, handed providers a venue where they win most of the time. Four years of data proves it. The practices treating IDR as an operational competency — not an afterthought, and not a fee they pay someone else forever — are the ones getting paid what the care was worth.
Dr. Abrahams is a board-certified neurosurgeon and founder and president of New York Brain & Spine Surgery in White Plains. He is also the founder of Sydra, an AI-powered platform for the No Surprises Act IDR process built on state and federal determination data.
