The Trump administration has finalized an overhaul of the No Surprises Act’s independent dispute resolution process, establishing a centralized disputes gateway, creating a new federal payer registry, and reducing administrative fees.
The final rule, issued jointly by HHS, the Labor Department, Treasury and the Office of Personnel Management on May 28, comes as the IDR system has logged more than 5 million disputes since launching in April 2022, far surpassing the 17,000 annual filings regulators originally projected. The volume has generated at least $5 billion in costs since 2022, including $2.8 billion in administrative expenses alone.
The rule, first proposed in late 2023, stalled for more than two years amid a series of legal challenges to the broader IDR framework and a lengthy regulatory review process. Payers, employer groups and lawmakers had urged federal action during that period, arguing a handful of provider groups had exploited the process for financial gain. Providers have been winning roughly 85% to 88% of disputes, with median payment determinations reaching 459% of the qualifying payment amount in 2024. Four groups, including Team Health, SCP Health, Radiology Partners and HaloMD, have accounted for the majority of dispute filings.
Payers have pursued an aggressive litigation strategy in response, filing lawsuits against provider groups and medical billing vendors that allege the companies flooded the IDR process with ineligible or inflated claims. In recent weeks, federal judges in California and Texas dismissed lawsuits brought by Elevance Health and BCBS Texas against HaloMD, and a Florida court dismissed an Aetna suit against Radiology Partners, with each ruling finding that federal and arbitration law narrowly constrains judicial review of IDR outcomes.
Elevance separately rolled out a policy penalizing hospitals 10% for using out-of-network providers across 11 states, which the company said was a response to “IDR abuse.” Indiana passed legislation blocking the policy in February (a notable rebuke given Elevance is headquartered in Indianapolis), and the California Hospital Association sued to block it in May. Fourteen House lawmakers also previously called for a federal investigation of the policy.
Here are five things to know about the final rule:
1. The per-dispute administrative fee will be lowered from $115 to $15 per party, taking effect five business days after the rule’s publication in the Federal Register. Separately, if either party fails to pay its administrative or certified IDR entity fee by the time its offer is due, that offer will not be considered received, though the financial obligation remains.
2. The rule lays the groundwork for the IDR Gateway, a single platform rolling out in phases this year where users can initiate disputes, track the status of a case and manage activity. The gateway replaces the current single-use web form system that generated a backlog of 90,000 claims within months of the process launching in 2022. Additional features, including in-portal negotiation tools, are expected to roll out over time.
3. Payers subject to the IDR process will be required to register with the federal government and receive a unique registration number. The registry is designed to help providers identify the correct payer and plan type when initiating disputes, and to help certified IDR entities resolve eligibility questions faster. The registry will also give CMS and OPM a tool for enforcement. Registration requirements take effect 90 business days after CMS issues guidance confirming the registry platform is live.
4. The rule broadens the circumstances under which multiple claims can be grouped into a single “batched” dispute, which reduces costs for both parties. Claims can now be batched when they involve a single patient on the same or consecutive dates of service billed together; when claims share the same service code; or when anesthesiology, radiology, pathology and laboratory claims fall within the same CPT code section. At the same time, batched disputes are now capped at 50 line items to allow certified IDR entities to process cases in a timely and financially sustainable way.
5. The rule formalizes the 30-business-day open negotiation period that precedes IDR filing. Going forward, parties must initiate that period through the federal portal, and the opposing party must submit a formal response by the 15th business day. Certified IDR entities must now complete eligibility determinations within five business days of being selected. The changes come after federal officials found that many parties were bypassing meaningful negotiation, with some open negotiation notices bundling thousands of items and services.
Industry statements:
Blue Cross Blue Shield Association
“We applaud the Trump administration’s focus on fixing the IDR process. This rule makes meaningful progress to reduce administrative burdens and streamline the process. We encourage leaders to use this positive momentum to take additional actions—focusing on solutions to stem the flood of ineligible claims into arbitration and awards that often far exceed what providers typically receive for a service. Cracking down on abuse, eliminating waste and delivering more transparency will save money for consumers and businesses,” David Merritt, senior vice president of external affairs, said.
Federation of American Hospitals
“The No Surprises Act is critical to protecting patients from unexpected out-of-pocket costs, and today the Administration took important steps to strengthen the law by increasing transparency, improving accountability, and reinforcing insurers’ obligations. By requiring clearer payment information, more meaningful engagement during negotiations, and stronger oversight of the IDR process, the final rule helps ensure the system works more fairly and efficiently. We look forward to continuing to work with the Administration to implement these regulations and ensure the law continues to protect patients while supporting a fair, transparent dispute resolution process,” President and CEO Charlene MacDonald said.
Federal Hearings & Appeals Services
“We are confident the new rules will deliver a better, smarter, and more efficient IDR process. Specifically, the enhanced regulations governing open negotiations, batching, and information exchange between parties will clarify the process and reduce the number of ineligible filings that enter the process today. The new IDR Gateway, expected to launch in phases later this year, also will drive greater efficiency throughout the IDR process,” CEO James Bobeck said.
Coalition Against Surprise Medical Billing
“Today’s final rule takes initial steps toward greater transparency and communications between all parties as part of the IDR process. However, more needs to be done to crack down on the ongoing abuse and misuse of IDR by some out-of-network doctors, private equity-backed providers, and IDR middlemen.
“Patients and employers cannot afford continued exploitation of the law’s IDR process. Additional reforms are needed to address the flood of disputes from IDR middlemen and the misaligned incentives driving inflationary awards to a handful of private equity-backed providers. CASMB urges Congress and the Trump administration to provide rigorous oversight of persistent bad actor providers and IDR middlemen and advance additional changes so that the No Surprises Act fully delivers on its promise of protecting consumers and reducing healthcare costs.”
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