Nearly 40% of IDR Disputes Deemed Ineligible

According to a joint report released by AHIP and the Blue Cross Blue Shield Association (BCBSA), health insurers identified 39% of all out-of-network disputes submitted to the federal IDR process as ineligible. The percentage was even higher for non-emergency services, where 45% of disputes allegedly failed to meet eligibility requirements.

Insurers argue that some providers are flooding the IDR system with disputes in an effort to secure higher reimbursements, even when claims do not qualify under the No Surprises Act (NSA).

Surprise Billing Protections Are Working—But at a Cost

Data from 2024 shows that nearly 20 million healthcare claims met the criteria for federal surprise billing protections, preventing millions of unexpected medical bills for patients. Additionally, 76% of claims were resolved without arbitration after providers accepted the insurer’s initial payment.

However, insurers warn that the operating costs of the IDR system continue to rise sharply, largely due to the volume of disputes—many of which should never have entered the process.

Common Reasons Claims Were Ineligible

The report outlines several recurring issues found in disputed claims, including:

• Services covered under Medicare or Medicaid
• Disputes that were already resolved through IDR and resubmitted
• Claims involving in-network providers
• Services governed by state surprise billing laws, not federal rules

Insurers also claim that IDR entities (IDREs) are failing to adequately screen disputes, resulting in payment determinations being issued for claims that are legally ineligible.

How the IDR Process Is Supposed to Work

The IDR process was established under the No Surprises Act to resolve payment disputes for specific out-of-network services, including:

• Emergency services
• Non-emergency services provided at in-network facilities
• Out-of-network air ambulance services

To qualify, claims must meet strict procedural requirements such as timely filing, completion of open negotiations, proper batching rules, and confirmation that no applicable state law applies.

Payment Timelines and Ongoing Challenges

Despite administrative challenges, insurers report that nearly three-quarters of arbitration awards are paid within 30 days, with 41% paid within just 15 days. When delays occur, they are most often linked to provider submission errors—such as missing documentation or incorrect contact information—or backlogs caused by the high volume of cases.

Financial Impact on the Healthcare System

AHIP and BCBSA emphasize that the IDR process is expensive, diverting funds that could otherwise support patient care, reduce premiums, or lower out-of-pocket costs. They argue that repeated submission of ineligible disputes further inflates administrative costs and burdens the system.

Legislative Developments to Watch

In July, lawmakers introduced the No Surprises Enforcement Act, which would impose fines on insurers that fail to pay providers within 30 days after losing an IDR dispute. Supporters of the bill stress that it does not affect patient protections or increase patient costs under the No Surprises Act.

While the IDR process has successfully reduced surprise medical bills for patients, insurers warn that misuse and inadequate oversight may undermine its effectiveness. As policymakers consider new enforcement measures, the balance between fair provider reimbursement, system efficiency, and patient protection remains at the center of the debate.

How No Surprise Bill Can Help

No Surprise Bill is a trusted resource dedicated to helping patients, providers, and healthcare stakeholders understand the No Surprises Act and the federal IDR process.

As disputes between insurers and providers increase, knowing what qualifies for IDR—and what does not—is essential to protecting patients from unnecessary costs and confusion. Our platform breaks down complex billing rules, eligibility requirements, and dispute resolution timelines in clear, practical terms.

Visit us to learn how the IDR process protects patients and promotes fair billing.