In short: The No Surprises Act (NSA) is the federal law, effective January 2022, that protects patients from most surprise out-of-network bills for emergency care and certain non-emergency services delivered at in-network facilities. For practices, the operational heart of the law is the Independent Dispute Resolution (IDR) process — an arbitration path for settling out-of-network payment disputes with payers. More than three years in, IDR volume has far exceeded expectations, providers win most cases, and the rules are still shifting through 2026 court decisions and a new federal operations rule.
Why the No Surprises Act still matters to your practice in 2026
Four years after it took effect, the No Surprises Act is not a settled area of billing — it is one of the most active. Dispute volume keeps climbing, courts keep reshaping the payment math, and a major federal rule finalized in 2026 is about to change how — and how often — practices use arbitration. For any practice that treats out-of-network patients, or whose claims land in emergency and facility settings, the financial stakes are real and the compliance workflow is not optional.
This guide walks through where the law stands now, what the IDR data actually shows, the court fights that affect your reimbursement, and the concrete steps a practice can take to protect revenue without adding administrative drag.
What does the No Surprises Act actually require?
At its core, the NSA does three things that touch your front office and your billing team:
- It limits balance billing. Patients can’t be balance-billed beyond in-network cost sharing for emergency services, air ambulance services, and non-emergency care delivered by out-of-network providers at in-network facilities. Their cost-sharing is based on the Qualifying Payment Amount (QPA), not the provider’s full charge.
- It requires good faith estimates. Self-pay and uninsured patients must receive an up-front estimate of expected charges.
- It routes payment disputes into IDR. Provider–payer disagreements over out-of-network rates go into a 30-day open negotiation and, if that fails, into federal IDR arbitration.
The result is a firm line between the patient and the payment fight: patients pay in-network-level cost sharing, and the provider and the plan argue over the rest through the federal process.
What is the QPA — and why is it still contested?
The QPA is meant to represent the median in-network rate for a service in a geographic market, and it anchors both patient cost-sharing and the arbitration process. The problem: how the QPA is calculated has been litigated for years, primarily through the Texas Medical Association (TMA) series of lawsuits.
Here’s the practical state of play for 2026. Federal regulators have extended enforcement discretion on QPA methodology, allowing plans to rely on QPAs calculated under the 2021 methodology for items and services furnished before February 1, 2026, while the courts sort out the rules. In May 2025, the full Fifth Circuit agreed to rehear the key case en banc, which reinstated an earlier district court ruling as binding for now. A decision could come at any time — and if it changes the QPA math, it can move both patient cost-sharing and the reimbursement your practice ultimately collects.
The takeaway for practices: the number that drives your out-of-network reimbursement is a moving target. It’s worth confirming that the payers you work with are disclosing QPA information on request and calculating it in good faith.
How is the IDR process actually going?
The data tells a clear story: far more disputes, still tilted toward providers.
- Volume has blown past projections. Parties submitted about 1.2 million new disputes to the IDR portal in the first half of 2025 — more than double the same period a year earlier — bringing the running total to roughly 3.4 million disputes from 2022 through mid-2025.
- Providers file, and providers win. In the first half of 2025, providers and facilities initiated 99.9% of all disputes, and providers have prevailed in roughly 88% of arbitration determinations, per federal data. Winning awards have often run well above the QPA benchmark.
- The backlog is finally clearing. After years of falling behind, arbiters have caught up — by early 2026, monthly dispute closures were running roughly even with new filings, a sharp turnaround from the multi-hundred-thousand-case backlog of earlier years.
- Eligibility is the sticking point. Roughly one in five disputes submitted in the first half of 2025 were actually ineligible for IDR, and sorting them out is a primary cause of delay. Filing disputes that don’t qualify wastes fees and clogs the process.
What changed with the 2026 IDR operations final rule?
In May 2026, federal regulators released the long-awaited IDR operations final rule, aimed at streamlining communication between payers, providers, and arbiters and clarifying timelines. Two changes matter most for practices.
The administrative fee dropped sharply. For disputes initiated on or after June 11, 2026, the federal IDR administrative fee is $15 per party per dispute, down from $115. That materially lowers the cost of bringing a dispute — which many observers expect to push volume even higher in the near term.
Eligibility and batching rules are being tightened and clarified. The rule revises how similar claims can be batched and adds eligibility-review steps, with several provisions phasing in months after publication rather than immediately. The intent is fewer ineligible filings and faster determinations over time.
The net effect: it’s getting cheaper to file, and the rules of what you can file are being redrawn at the same time. Practices that understand both changes will be positioned to use IDR where it pays off — and avoid wasting fees where it doesn’t.
Three compliance traps that catch practices
- Trap 1 — Treating IDR as free money. The low new fee makes arbitration tempting, but ineligible or poorly documented filings burn fees and staff time. Fix: screen every potential dispute for eligibility and complete the open-negotiation period before initiating.
- Trap 2 — Weak good faith estimate workflows. Estimates for self-pay and uninsured patients are a live compliance obligation, not a formality. Fix: build a standard estimate template and a documented process so estimates go out on time, every time.
- Trap 3 — Accepting payer QPAs at face value. With the methodology in flux, some QPA figures may be low or under-disclosed. Fix: request QPA disclosures, track them, and flag calculations that look inconsistent for review or dispute.
How can a practice reduce the administrative burden?
The honest answer is that NSA compliance is now a specialized workflow, not a task you bolt onto an already-stretched front desk. The practices that handle it well tend to do a few things consistently: they verify network status and benefits before service; they document medical necessity and complexity thoroughly so it supports a strong IDR offer; they hit every deadline in the open-negotiation and IDR timeline; and they track QPA disclosures and payment turnaround so nothing slips.
Done in-house, that’s real staff time. Done through an experienced revenue cycle partner, it becomes a managed process with clear accountability — and your clinical team stays focused on patients.
How AMS Solutions helps practices navigate the No Surprises Act
AMS Solutions has provided physician medical billing services since 1992, with AAPC-certified coders and a full revenue cycle management operation. For practices dealing with out-of-network and surprise-billing exposure, that means eligibility and benefits verification on the front end, documentation and coding built to support clean claims and strong dispute positions, disciplined follow-up on open-negotiation and IDR timelines, and clear visibility into where reimbursement is leaking. We don’t promise specific arbitration outcomes — we build the workflow and documentation that give your claims their best footing and keep your team out of the administrative weeds.
If out-of-network claims, denials, or aging receivables are draining time and revenue, we offer a free billing analysis to show you where the leakage is and what a cleaner process would look like. There’s no long-term contract required to start. See our case studies for measurable results from real practices.
Frequently asked questions
Possibly. The law reaches out-of-network claims that arise at in-network facilities and in emergency settings, so even a largely in-network practice can end up with claims that fall under the NSA and its IDR process.
The QPA is the benchmark rate — roughly the median in-network rate for a service in a market — and it sets patient cost-sharing. The IDR award is the payment amount an arbiter selects between the provider’s and the plan’s offers when the two sides can’t agree. Awards frequently come in above the QPA.
Not automatically. The lower fee makes marginal disputes more viable, but ineligible or poorly documented filings still waste time and money. Screen for eligibility, complete open negotiation first, and file where the expected recovery justifies the effort.
Usually not directly. Most courts have found that the No Surprises Act does not give providers a private right of action to enforce IDR awards, and have instead directed providers to complain to CMS about plan noncompliance. This remains an area of active litigation.
Yes. Good faith estimate requirements for self-pay and uninsured patients remain in effect and are a standing compliance obligation, separate from the IDR payment process.
Sources: Centers for Medicare & Medicaid Services (CMS) No Surprises Act IDR reports and notices; Health Affairs Forefront analysis of 2025 IDR data; Healthcare Dive reporting on CMS IDR data and the 2026 final rule; McDermott+ analysis of the 2026 NSA regulatory agenda; Georgetown Center on Health Insurance Reforms.
