On May 28, 2026, the Departments of Health and Human Services, Labor, and Treasury, alongside the Office of Personnel Management, released the final rule to the Independent Dispute Resolution (IDR) process under the No Surprises Act, implementing long-awaited operational reforms. The rule, designated CMS-9897-F, seeks to address systemic inefficiencies that have accumulated over four years of troubled implementation¹.
The No Surprises Act, enacted as part of the Consolidated Appropriations Act of 2021, was designed to protect patients from unexpected out-of-network bills while establishing an unbiased arbitration system for resolving payment disputes between providers and insurers. Under this system, each party submits a payment offer to a certified IDR entity, which selects the final payment after weighing a list of statutory factors, including the qualifying payment amount (QPA)—an insurer’s 2019 median in-network rate for the service, indexed for inflation². The IDR portal opened in April 2022 but was immediately overwhelmed: federal officials had projected approximately 17,000 disputes per year, yet the system received over 5 million disputes by early 2026³.
The final rule addresses several critical bottlenecks in the IDR process of the No Surprises Act. Most visibly, the administrative filing fee drops from $115 to $15 per party per dispute, lowering barriers to participation while preserving program solvency¹. Batched disputes are now capped at 50 line items, streamlining case management. Payers are required to use standardized Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs) on remittances sent to non-contracted providers, enabling physicians to identify IDR-eligible claims earlier and reduce unnecessary filings⁴. The rule also introduces clearer open negotiation timelines and enforceable expectations for good-faith engagement by both parties.
The American Society of Anesthesiologists (ASA), American College of Emergency Physicians (ACEP), and American College of Radiology (ACR) jointly applauded the rule, emphasizing that it better aligns the process with congressional intent and limits opportunities for gaming by insurers. The societies cautioned, however, that the reforms will deliver on their promise only if backed by rigorous enforcement, including real consequences for plans that delay payment after a provider prevails⁴.
The final rule arrives against a backdrop of intense litigation. A series of challenges brought by the Texas Medical Association (TMA) questioned how QPA is calculated by insurers and weighed by IDR entities in the arbitration process. In August 2022, federal rules instructing arbitrators to consider the QPA first were vacated by the Fifth Circuit in TMA II.
A subsequent challenge, TMA III, overturned portions of the QPA calculation methodology, and in May 2025, the full Fifth Circuit granted en banc rehearing of the appellate panel’s partial reversal of that decision, leaving QPA compliance obligations in a state of continued uncertainty⁵. In January 2025, the Departments issued FAQ Part 69, extending enforcement discretion for plans calculating QPAs under either the 2021 or 2023 methodologies for services furnished before August 1, 2025, pending resolution of the litigation⁵.
Congressional Research Service analysis of 2024 IDR data reveals the landscape of arbitration so far. Providers prevailed in approximately 85% of payment determinations that year, up from 80% in 2023, with insurers defaulting (failing to submit an offer or pay fees) at an increasing rate. For surgery and neurology/neuromuscular procedures, median prevailing offers reached 13 and 17 times the QPA, respectively, by the fourth quarter of 2024². The first half of 2025 continued the trend while also highlighting growing concerns: providers won 88% of disputes, administrative costs in six months approached the total costs of the prior three years combined, and a new wave of insurer lawsuits against IDR middlemen alleged widespread submission of ineligible claims³.
Whether the May 2026 final rule can meaningfully stabilize the IDR system depends on factors still unresolved. The Fifth Circuit’s en banc decision on QPA methodology remains pending, and the Supreme Court’s January 2026 refusal to hear Guardian Flight’s appeal confirmed that providers generally cannot bring private civil actions to enforce IDR awards, leaving complaint to CMS as the primary enforcement mechanism³. The rule’s success will ultimately rest on whether its transparency and communication reforms translate into a process that functions as the NSA’s authors intended: keeping patients out of billing disputes while ensuring fair, market-grounded payment for out-of-network care.
References
- Centers for Medicare & Medicaid Services. Federal Rule Takes Aim at Health Care Bureaucracy, Reducing Dispute Fees, and Boosting Transparency. CMS Newsroom Press Release, May 28, 2026. https://www.cms.gov/newsroom/press-releases/federal-rule-takes-aim-health-care-bureaucracy-reducing-dispute-fees-boosting-transparency
- Rosso, R.J. & Shen, W.W. No Surprises Act (NSA) Independent Dispute Resolution (IDR) Process Data Analysis for 2024. Congressional Research Service Report R48738, November 26, 2025. https://crsreports.congress.gov/product/pdf/R/R48738
- Hoadley, J., Watts, K., Keith, K. & DeGarmo, E. The No Surprises Act IDR process: an early look at 2025 data. Health Affairs Forefront, March 20, 2026. https://doi.org/10.1377/forefront.20260318.548269
- American Society of Anesthesiologists, American College of Emergency Physicians & American College of Radiology. ACEP, ACR and ASA Applaud Final IDR Operations Rule as Major Step Forward for No Surprises Act Implementation. Newswise, May 29, 2026. https://www.newswise.com/articles/acep-acr-and-asa-applaud-final-idr-operations-rule-as-major-step-forward-for-no-surprises-act-implementation/
- O’Brien, K., Davis, J., McCormick, D.E., Gelfman, J.B. & Hoey, A. Breaking down the new No Surprises Act FAQs post-TMA III (June 2025 update). McDermott+, June 6, 2025. https://www.mcdermottplus.com/insights/breaking-down-the-new-no-surprises-act-faqs-post-tma-iii/
- Centers for Medicare & Medicaid Services. Independent Dispute Resolution Reports. CMS No Surprises Act Policies & Resources (updated bi-monthly). https://www.cms.gov/nosurprises/policies-and-resources/reports
