Understanding In-Network vs. Out-of-Network Care

When choosing a doctor or hospital, most patients check whether the provider is in-network. In-network providers have negotiated contracts with health insurers, agreeing to predetermined reimbursement rates. This creates predictability for patients — typically limiting their responsibility to copays, deductibles, and coinsurance.

Out-of-network providers, by contrast, have not agreed to those rates and may bill significantly higher amounts. Historically, patients who unknowingly received out-of-network services — particularly during emergencies or at in-network facilities — could face “surprise bills” totaling thousands or even tens of thousands of dollars.

What the No Surprises Act Changed

Implemented in 2022, the No Surprises Act prohibits out-of-network providers from balance billing patients in emergency situations or when care is provided at an in-network facility (such as anesthesia, radiology, or pathology services).

Instead of billing the patient, providers must bill the health plan. If the provider disputes the insurer’s payment, both parties enter a 30-day negotiation window. If no agreement is reached, the dispute proceeds to the Independent Dispute Resolution (IDR) process — a federally established arbitration system.

Where Concerns Are Emerging

Under the IDR process, a third-party arbitrator must choose either:

• The amount requested by the provider
• The amount offered by the health plan

There is no middle ground. No compromise. The arbitrator selects one number.

Recent reporting indicates:

• A sharp increase in IDR case volume (40% higher in 2025 compared to 2024)
• Providers winning more than 85% of disputes
• Arbitration awards often reaching three to four times higher than typical in-network rates

For example, some analyses show:

• A procedure priced at $1,232 in-network settling for over $14,000 in arbitration
• Imaging services rising from roughly $608 in-network to over $3,300 through dispute resolution

These outcomes have raised concerns among employers and plan sponsors who ultimately fund health benefits for millions of Americans. As arbitration awards rise, those additional costs may translate into higher premiums, increased deductibles, or reduced benefits for employees.

The goal should not be to undermine legitimate physician reimbursement. Instead, it should be to ensure the system does not unintentionally drive healthcare costs higher for employers and families.

Healthcare reform often produces ripple effects. As lawmakers evaluate the next phase of adjustments to the No Surprises Act, the challenge will be balancing consumer protection with sustainable cost controls — ensuring the system works as intended for patients, providers, and payers alike.

No Surprise Bill helps providers, employers, and healthcare organizations navigate evolving No Surprises Act billing practices with clarity and compliance. As arbitration trends and IDR disputes continue to reshape reimbursement strategies, having the right legal and regulatory insight is critical.

Our team works to protect your financial interests while maintaining full compliance with federal requirements. Visit us today to learn how we can support your organization and strengthen your billing strategy with confidence.