Independent dispute resolution outcomes for planned procedures under the No Surprises Act

Abstract

Introduction

The No Surprises Act (NSA) protects commercially insured patients from balance bills. Providers win most disputes under the NSA's independent dispute resolution (IDR) process, with awarded payments (awards) several times in-network rates. While most disputes involve emergency care, awards for planned procedures may be even higher. This study quantifies awards from the NSA's IDR process for certain planned procedures (eg, plastic and spine surgery).

Methods

Using Elevance Health dispute data, this study compares awards from the 25 most common planned surgical and endoscopic procedures in 2024-2026 to the qualifying payment amount (QPA; defined by the NSA), in-network contracted rates (from transparency in coverage data), in-network Elevance Health claims, and Medicare prices.

Results

The mean (median) cost of awards for disputed claim lines was $39 875 ($28 000), while the mean (median) QPA was $798 ($441). The median ratio of awards to benchmarks was 52.9 times the QPA, 53.4 times the median contracted rate, 28.5 times the median in-network paid claim, and 67.4 times the Medicare price. Providers won 89.4% of disputed claim lines, with little variation by provider or insurer offer.

Conclusion

IDR awards for certain planned procedures are extreme, with the median award exceeding 50 times the QPA.

Key Takeaways.

• Under the No Surprises Act (NSA), out-of-network providers may submit disputes regarding payment for some nonemergency procedures to an independent dispute resolution (IDR) process.

• This analysis found that awards to providers from the IDR process for certain planned procedures (eg, plastic surgery and spine surgery) are extreme, averaging more than 50 times benchmarks that reflect in-network commercial rates and Medicare rates.

Introduction

The No Surprises Act (NSA), which went into effect in January 2022, protects commercially insured patients nationally from surprise medical bills, which are charges for out-of-network care that patients did not anticipate or could not prevent. The NSA covers facility-based emergency care, nonemergency (planned) care at in-network facilities, and air ambulance services. Some surgical procedures, when performed by an out-of-network provider at an in-network facility, may be subject to the NSA. Before the NSA was passed, the Congressional Budget Office predicted that the law would lead to a decrease in overall healthcare costs.¹

Dispute resolution under the NSA

When an out-of-network provider does not want to accept the insurer's payment for care subject to the NSA, the provider must negotiate with the insurer to determine payment for the out-of-network service. If negotiations fail after 30 days, the provider may initiate a dispute through the NSA's independent dispute resolution (IDR) process. The process, which is conducted by a certified Independent Dispute Resolution Entity (IDRE), is “baseball style,” meaning that the IDRE chooses either the offer of the insurer or that of the provider as the final award (required payment) to the provider.

IDREs may consider several factors when choosing one of the offers, including the qualifying payment amount (QPA) (ie, the insurer or plan's median in-network rate, which is also used in the calculation of patient cost sharing under the NSA); the training, experience, and market share of the provider; and patient acuity and complexity. Usual and customary charges and public payer (eg, Medicare) rates are prohibited from being considered by the IDRE. The original implementing regulations of the NSA directed IDREs to favor offers close to the QPA. However, the requirement to prioritize the QPA over other factors was struck down in court, and research has shown that providers are consistently receiving awards several times the QPA.^2-5

The QPA is defined by the NSA as a health plan's median in-network contracted rate for the same service in the same geographic region, based on 2019 rates and adjusted for inflation, and Centers for Medicare & Medicaid Services (CMS) regulations further clarify the definition. However, some provider organizations and associations have argued that the QPA is artificially low, particularly due to the inclusion of contracted rates of providers who rarely or never submit claims for those procedures, known as “ghost rates,” which are likely to be lower than the rates of providers who perform the procedures frequently.⁶

Nonemergency care under the NSA

Planned procedures may fall under the NSA if both the facility and the primary surgeon or physician are in-network, but supporting providers—such as radiologists or anesthesiologists, who were likely not chosen by the patient—are out-of-network. In this type of case, the primary provider receives payment based on the negotiated, in-network rate, but the supporting providers may contest the payment they receive from the insurer and submit the claim to the IDR process.

Planned procedures in which the primary provider is out-of-network, but the facility is in-network, may also result in the IDR process. The NSA anticipated that patients may choose to seek out-of-network care and required that, to balance bill the patient (ie, charge them for more than is covered by insurance), the out-of-network provider must give the patient a notice that explains the waiver of NSA protections and provides a good faith estimate of the expected out-of-pocket cost.

However, if the patient does not consent to be billed for the out-of-network care—or if the provider never notified the patient—the provider may still perform the procedure, and rather than balance bill the patient (which is prohibited by the law absent written consent to waive NSA protections), the provider may initiate the IDR process. In theory, this scenario should become more limited due to the Federal IDR Operations final rule released on May 28, 2026, which requires providers and facilities to attest that disputed services do not qualify for the notice-and-consent exception before proceeding through the IDR process,⁷ though it is not yet clear how much this requirement will alter the composition of disputes in practice.

Objective

Previous research, which has mainly focused on emergency care, has shown that providers win a large majority of disputes under the NSA, and their awards are several times in-network rates for the same procedures.^2-5 Recent case reports suggest that the dispute resolution process is leading to even more expensive care for planned out-of-network procedures.^8-10 Therefore, this study quantifies the awards from the IDR process under the NSA in 2024 through early 2026 for certain planned, primarily elective, procedures (eg, plastic surgery and spine surgery) compared with several benchmarks, including the QPA, in-network commercial rates, and Medicare rates. This analysis includes surgical and endoscopic procedures performed by primary surgeons/physicians or assistant surgeons and does not include ancillary services (eg, anesthesia) performed during a planned procedure.

Data and methods

Data and study sample

This retrospective study uses NSA IDR data from Elevance Health affiliates’ and subsidiaries’ (Elevance Health) disputes for planned (nonemergency) surgical and endoscopic procedures that were determined by an IDRE between January 1, 2024, and February 1, 2026. Specifically, this paper focuses on the 25 most common CPT (procedure) codes for planned surgical and endoscopic procedures in Elevance Health's IDR data (Appendix Table S1). Of these 25 codes, 11 are related to spine surgery, 8 are related to plastic surgery, and 6 are for other procedures, including colonoscopy and hysteroscopy. Disputed claim lines for these 25 codes represented ∼34% of all disputed claim lines with CPT codes for surgical or endoscopic procedures (including potentially emergency procedures, such as appendectomy, which were removed from the top 25 code list) that met the other inclusion criteria (below) in the Elevance Health IDR data.

Disputed claim lines were included if they met the following criteria: The dispute had been resolved, the claim line was from a professional (rather than facility) claim, and the CPT and ZIP code were not missing. Exclusions were made for duplicate claims or disputes, care occurring in an emergency department, claims for Medicare or Medicaid beneficiaries, in-network care, and cases in which data limitations did not allow for the determination of the award at the claim line (rather than dispute) level.

The dispute data contained the CPT code(s) and modifier codes of the care under dispute, the location of care, the QPA, the provider and insurer offers, the winner/decision, and the final amount awarded to the provider, among other information.

The dispute data were linked, based on the CPT code and geography (at the core-based statistical area [CBSA]-state level), to 3 other data sources: (1) payer transparency in coverage (TiC) data (obtained through Turquoise Health) for in-network care—both from Elevance Health and other insurers—to compare IDR awards with industry-wide median in-network contracted rates; (2) Elevance Health in-network professional claims in 2024-2025, to compare IDR awards with in-network costs for similar procedures; and (3) Medicare fee-for-service (FFS) pricing data (from CMS), to compare IDR awards with Medicare prices.

Outcomes and analysis

The unit of analysis was the claim line. While most disputes (82%) in the study sample only had one claim line, some had multiple; in these cases, the award from the dispute was broken down into the component parts by claim line, and only claim lines with the procedure codes of interest were included.

For each disputed claim line, we compared the final award to: (1) the QPA; (2) the median nonzero in-network contracted rate across the industry (from the TiC data); (3) the median nonzero in-network Elevance Health allowed amount in claims (with each paid claim line counting as one observation); and (4) FFS Medicare prices (see data sources above), all for the same CPT code in the same CBSA and state. To create an apples-to-apples comparison for each disputed claim line, the benchmarks were adjusted to account for the quantity (billed units) and for procedure modifiers in the disputed claim line (except for the QPA, which already accounts for quantity and modifiers). For example, if a disputed line contained modifier 50 (indicating a bilateral procedure and requiring a 50% increase in pay), the benchmarks for that line—which are based on prices/payments for that procedure absent any modifiers—would be increased by 50% before calculating the ratio of the award to the benchmark. Another example is modifiers 80, 81, 82, or AS for assistant surgeons or assistants at surgery (hereafter, “assistant surgeons”); the presence of these codes would result in an 84%-86% decrease in the benchmark. See Appendix Note S1 for further explanation of this calculation, including a validation of this approach for the in-network claims benchmark using specific claims examples.

This paper is descriptive in nature. Medians and means of the ratios of awards to benchmarks were calculated at the disputed claim line level. We stratified outcomes by dispute characteristics such as procedure type, provider type, and year. We also described the unadjusted relationship between provider and insurer offers and the probability of a provider winning. Analyses were conducted in SAS version 9.4 and R version 4.4.0.

Limitations

This study has a few limitations. First, it is limited to the 25 most common planned surgical or endoscopic procedures in Elevance Health dispute data and may not be generalizable to all disputes for planned procedures—they represent one third of disputed claim lines for all surgical and endoscopic procedures (including some potentially emergency procedures) meeting the study criteria—or disputes from other insurers. Second, ZIP codes of the disputed claim lines and the claims-based benchmarks were based on submitted claims, and it is possible that some do not match the location where care occurred (if a billing address was submitted and it differed from where the care occurred). Finally, early 2024 data were not complete in our data source (due to changes in Elevance Health data tracking systems), which may introduce some bias when looking at trends over the year, though we have no reason to believe that the missingness was associated with outcomes.

Results

Description of disputed claim lines

7304 claim lines with CPT codes for the procedures of interest from Elevance Health disputes met the inclusion criteria, representing 2.2% of total resolved disputed claim lines in the Elevance Health data during the study period. These 7304 claim lines came from 483 unique clinicians, 3706 unique surgical/endoscopic episodes, 4628 unique claims, and 6594 unique disputes. This indicates that each surgical/endoscopic episode in the sample gave rise to an average of 1.8 unique disputes, not including disputes for any ancillary services. The top 50 clinicians were responsible for half (49.4%) of disputed claim lines in the study sample. Of the more than 5100 disputed claim lines for which health plan data could be linked to the dispute records, 90% involved health plans sponsored by self-insured employers.

The sample of disputed claim lines, the percentage won by providers, and the mean awards are displayed by several dispute characteristics in Table 1. Overall, 6535 (89.5%) disputed claim lines were won by providers. The mean (median) cost of the award for a disputed claim line was $39 875 ($28 000), while the mean (median) QPA was $798 ($441). 3115 (42.6%) disputed claim lines for planned procedures were for spine surgeries, 2450 (33.5%) were for plastic surgeries, and 1739 (23.8%) were for other procedures (though a few of these procedures may also be related to spine or plastic surgery). 2355 (32.2%) of the disputed claim lines were from assistant surgeons, split evenly (49.4% and 50.6%, respectively) between physicians (modifier 80-82) and nonphysicians (modifier AS); ∼32% of these were from surgeries where the patient's primary surgeon was in-network, and the remainder were from surgeries where the primary surgeon was also out-of-network. 586 (8.0%) of the disputed claim lines were from co-surgeons (modifier 62, which results in a 37% decrease in payment). More than 90% of the disputes came from New York, California, and Connecticut; the remaining disputes came from the 11 other states where Elevance Health has commercial health plans.

Table 1.

Disputed claim line sample, awards, and ratios of awards to benchmarks by dispute characteristics.

	Sample	Provider win	Award	QPA ratio		Contracted prices (TiC) ratio		In-network claims ratio		FFS Medicare ratio
	(n, col %)	(row %)	Mean	Median	Mean	Median	Mean	Median	Mean	Median	Mean
Total	7304 (100.0)	89.5%	$39 875	52.9	118.6	53.7	118.8	28.6	73.8	67.4	144.8
Winner: Provider	6535 (89.5)	100.0%	$44 383	62.5	132.8	62.9	132.4	35.1	82.4	76.2	161.5
Winner: Insurer	769 (10.5)	0.0%	$1567	1.0	2.8	1.3	2.9	0.7	1.6	1.5	3.6
Category: Spine	3115 (42.6)	88.0%	$43 039	57.7	126.8	67.7	151.6	34.3	87.9	75.0	172.4
Category: Plastic	2450 (33.5)	89.7%	$45 157	35.1	103.2	28.2	92.8	15.0	51.4	34.8	123.6
Category: Other	1739 (23.8)	91.8%	$26 767	63.4	124.2	48.9	97.3	48.7	80.6	86.7	125.4
State: New York	4091 (56.0)	87.7%	$38 322	52.3	125.3	45.5	108.7	17.5	47.7	51.5	119.9
State: California	1979 (27.1)	90.7%	$44 496	63.1	132.7	70.7	160.3	66.2	125.7	100.3	193.9
State: Other	1234 (16.9)	93.4%	$37 614	29.4	62.3	32.4	84.1	29.1	76.6	54.7	148.9
Provider: Assistant surgeon	2355 (32.2)	88.9%	$40 254	146.2	246.3	196.6	268.8	109.0	164.0	237.9	322.1
Primary surgeon in-network	745 (10.2)	88.5%	$33 788	133.0	222.7	164.3	243.3	113.4	156.7	216.2	285.8
Primary surgeon out-of-network	1568 (21.5)	88.9%	$43 302	156.3	254.6	209.7	280.7	103.4	166.6	248.8	339.3
Provider: Co-surgeon	586 (8.0)	83.6%	$55 979	62.4	81.1	68.7	80.3	26.5	41.8	74.2	85.3
Provider: Primary surgeon/physician	4363 (59.7)	90.6%	$37 508	38.6	55.7	33.4	44.1	17.5	29.5	45.0	57.1

Abbreviations: FFS, fee-for-service; QPA, qualifying payment amount; TiC, transparency in coverage.

The medians and means represent the median and mean value of the ratio of the award to its calculated benchmark, with each disputed claim line counting once.

See Table 2 for the list of procedures included in spine, plastic, and other. The state is based on where the care occurred. Assistant surgeon is designated if the disputed claim line included modifiers AS, 80, 81, or 82; co-surgeon is designated if the disputed claim line included modifier 62.

The sum of assistant surgeon disputed claim lines with in-network and out-of-network primary surgeons does not add up to the total since we were unable to identify the primary surgeon in 42 cases.

Comparison to benchmarks

Figure 1 shows the awards the providers received compared to the 4 benchmarks of interest. For example, the first column for QPA shows that 8% of disputed claim lines received awards of up to 2 times the QPA; 14% had awards between 2 and 20 times the QPA; 25% had awards between 20 and 50 times the QPA; 23% had awards between 50 and 100 times the QPA; 22% had awards between 100 and 400 times the QPA; and 7% had awards more than 400 times the QPA. Only 0.6% of disputed claim lines had an award smaller than the QPA (included in the “up to 2 times” category).

Figure 1.

Percent of provider awards from disputed claim lines by the ratio of award to benchmark. Abbrevations: FFS, fee-for-service; QPA, qualifying payment amount; TiC, transparency in coverage. The contracted prices benchmark represents the median price across the industry from TiC data. The in-network claims benchmark is the median of the allowed amount from Elevance Health in-network professional claims. Sample size: QPA was not available in the dispute data for some of the disputes. Median contracted prices and in-network claims were not calculated when there were no prices/claims in the data for the combination of CPT code, geography, and timeframe of interest. FFS Medicare price benchmarks were available for all disputed lines.

The median and mean ratios of the awards to each benchmark are provided in Table 1. Overall, the median award was 52.9 times the QPA, 53.7 times the median contracted rate across payers (TiC), 28.6 times the median of in-network Elevance Health paid claims, and 67.4 times the Medicare FFS price. These ratios were even higher when limiting the analysis to the cases where the provider won. In cases where Elevance Health won, these ratios were close to one; for example, the median (mean) ratio to the QPA was 1.00 (2.8). Histograms showing the distribution of the ratio of awards to the 4 benchmarks by dispute winner are provided in Appendix Figure S1.

Table 1 also presents differences in the ratios of the awards to the 4 benchmarks by several dispute characteristics, including procedure category, state, and whether the claim was submitted by an assistant surgeon. While all categories had very high awards compared to the benchmarks, some were higher than others: spine surgeries tended to have awards slightly higher than plastic surgeries relative to benchmarks; California and New York had higher awards than other states; and assistant surgeons had much higher awards compared to their benchmarks (which were adjusted to 14%-16% of median prices)—approximately 4 times higher than primary surgeons/physicians. Assistant surgeons paired with out-of-network primary surgeons tended to have slightly higher awards compared to benchmarks than assistant surgeons paired with in-network primary surgeons.

Trends over time in the median and mean ratios of the award to the 4 benchmarks are displayed in Appendix Figure S2. The awards increased from early 2024 through mid-2025, though awards from disputes determined in the last quarter of 2025 appear to have fallen slightly. The mean award increased from $29 474 in 2024 to $42 197 in 2025, a 43% increase. These trends were similar by procedure type and provider role.

Table 2 presents the mean award and mean benchmarks stratified by CPT code, and Appendix Table S2 displays the same table with medians instead of means. The awards varied by CPT code, with 19 318 (breast reduction) having the highest mean award at $78 287 (compared to an associated FFS Medicare rate of $1173) and 15 771 (grafting via liposuction) having the lowest mean award at $13 085 (compared to an associated FFS Medicare rate of $500). For all CPT codes, the mean award was at least 21 times (and up to more than 151 times) the FFS Medicare rate. Appendix Table S3 shows the median and mean ratio of the award to the 4 benchmarks by CPT code, and Appendix Table S4 provides CPT code-specific mean awards by provider role (ie, primary surgeon/physician, assistant surgeon, and co-surgeon). The mean assistant surgeon award was higher than the mean primary surgeon/physician award in 7 of the 22 procedures with sufficient data.

Table 2.

Mean awards and benchmarks by CPT code.

CPT	Brief description	Category	Count	Award	QPA	Contracted price (TiC)	In-network claim	FFS Medicare
19 318	Breast reduction	Plastic	662	$78 287	$1138	$1357	$3196	$1173
58 662	Laparoscopy, surgical	Other	606	$34 537	$760	$575	$744	$479
22 853	Insertion of interbody biomechanical device(s)	Spine	549	$30 759	$365	$282	$603	$216
14 301	Adjacent tissue transfer or rearrangement	Plastic	386	$22 618	$610	$844	$1546	$716
63 047	Laminectomy, facetectomy and foraminotomy	Spine	381	$50 828	$1145	$846	$1374	$768
63 048	Laminectomy, facetectomy and foraminotomy	Spine	359	$28 108	$316	$240	$553	$186
43 239	Esophagogastroduo-denoscopy	Other	351	$15 408	$258	$266	$265	$143
14 302	Adjacent tissue transfer or rearrangement	Plastic	306	$27 813	$708	$752	$2076	$661
15 734	Muscle, myocutaneous, or fasciocutaneous flap; trunk	Plastic	283	$41 041	$1280	$1925	$3657	$1884
58 558	Hysteroscopy, surgical	Other	260	$16 926	$541	$633	$1005	$252
22 842	Posterior segmental instrumentation	Spine	253	$33 819	$754	$653	$1678	$518
19 380	Revision of reconstructed breast	Plastic	252	$45 723	$948	$1097	$2907	$1019
22 614	Arthrodesis, posterior or posterolateral technique, single interspace	Spine	246	$40 695	$1079	$678	$1876	$512
22 612	Arthrodesis, posterior or posterolateral technique, single interspace; lumbar	Spine	241	$60 371	$1282	$1122	$2730	$1017
22 845	Anterior instrumentation; 2 to 3 vertebral segments	Spine	236	$36 073	$591	$521	$1468	$448
22 558	Arthrodesis, anterior interbody; lumbar	Spine	223	$71 449	$1457	$915	$1397	$910
22 551	Arthrodesis, anterior interbody; cervical below C2	Spine	222	$55 679	$1383	$1319	$3964	$1195
45 380	Colonoscopy	Other	212	$18 125	$340	$435	$321	$208
63 030	Laminotomy (hemilaminectomy)	Spine	212	$52 236	$1224	$747	$1965	$659
15 777	Implantation of biologic implant	Plastic	204	$25 543	$307	$346	$699	$253
15 771	Grafting of autologous fat harvested by liposuction	Plastic	193	$13 085	$405	$636	$689	$500
22 840	Posterior nonsegmental instrumentation	Spine	193	$34 841	$764	$552	$1348	$456
64 722	Decompression; unspecified nerve(s)	Other	178	$57 348	$647	$464	$491	$476
19 357	Tissue expander placement in breast reconstruction	Plastic	164	$65 217	$1524	$1614	$3106	$1081
69 990	Microsurgical techniques	Other	132	$13 322	$280	$207	$890	$194

Abbreviations: FFS, fee-for-service; QPA, qualifying payment amount; TiC, transparency in coverage.

Provider and insurer offers and provider win rates

The distributions of insurer offers and provider offers compared with the median contracted rate across payers (from TiC data) are shown in Appendix Figure S3. Since providers won 89.4% of the cases, the distribution of provider offers looks similar to the distribution of awards (particularly the subset won by providers) presented in Appendix Figure S1. Meanwhile, the insurer typically offered less than 2 times and rarely offered more than 10 times the contracted prices benchmark. The insurer offered precisely the QPA 58.4% of the time, among cases when both QPA and offer data were available (n = 5200) (data not shown).

Figure 2 shows that providers won a similar percentage of disputed claim lines regardless of either their offer or the insurer's offer compared with the median contracted rate; providers offering less than 10 times the median contracted rate won 88.3% of disputed claim lines, compared with 89.5% of claim lines when they offered more than 400 times the median contracted rate. Similarly, provider win rates did not vary substantially based on insurer offer, except for a modest decrease (providers won 83.0%) when the insurer offered more than 5 times the median contracted rate.

Figure 2.

Provider win rates by ratio of provider and insurer offer to contracted prices benchmark. Abbreviation: TiC, transparency in coverage (ie, the data source for the contracted prices benchmark). Missing insurer offers may include cases where the insurer challenged the dispute as out of scope or ineligible and therefore did not submit an offer to the IDRE.

Discussion

Whereas prior research has shown that awards from the IDR process (including for emergency care, the most common type of dispute) are several times the QPA on average,^2-5 this analysis shows that in the case of the 25 most common planned procedures, awards are extremely high, with the median award being 53 times the QPA and the mean award being 119 times the QPA. This study also found that the median award was 29 times the median in-network claim for similar services and the mean award was 74 times the median in-network claim. IDREs are choosing the provider as the winner in 90% of disputed claim lines for these procedures, even though provider offers are much higher than what in-network providers receive. Furthermore, this trend has increased over the last 2 years.

The discrepancy between awards and benchmarks was especially pronounced for assistant surgeons, half of whom were awarded more than 147 times the QPA (in contrast with primary surgeons/physicians, who had a median award of 39 times the QPA), 195 times contracted prices (TiC), and 108 times in-network claims. These award-to-benchmark ratios were similar regardless of whether the assistant surgeon was working with an in-network or out-of-network primary surgeon. Claim lines with an assistant surgeon/assistant at surgery modifier indicate that a primary surgeon also billed for the same procedure; the assistant's payment is a second payment for the procedure of interest, which is why it is typically only paid at 16% (for physicians) or 14% (for nonphysicians) of the regularly contracted rate. The QPA and the benchmarks we calculated take this payment reduction into account. However, assistant surgeons have been winning awards with amounts similar to those of primary surgeons for these procedures, which is why their awards show even greater divergence from benchmarks.

Looking across the ratios of awards to the 4 different benchmarks included in this study, although the ratios of awards to in-network claims were extremely high, these ratios were still somewhat lower than the ratios to the QPA, indicating that the median claim is greater than the QPA. This is due to how the QPA is defined by the NSA, which is the median in-network contracted rate, whereas the median claim can be considered volume-weighted. It also suggests that more claims are submitted by providers whose rates are higher than the median rate, and it is possible that “ghost rates” are at least partially contributing to the lower QPA. In contrast, the median and mean ratios to the QPA and to the TiC benchmark are extremely close, indicating that industry-wide prices (captured by the TiC data) are similar to those from Elevance Health. This is expected because the QPA is statutorily based on median contracted rates, which are the same rates reported in the TiC data.

Nevertheless, the difference between the QPA/TiC and claims paid benchmarks pales in comparison to the difference between any of these benchmarks and the average IDR award. The QPA—often offered by the insurer in the IDR process—was approximately half of the average claim cost for procedures included in this analysis, representing a decrease of several hundred to one thousand dollars for most of these planned procedures. Relative to paid in-network claims, providers are requesting and IDREs are awarding amounts that are tens to hundreds of times higher, resulting in excess costs of tens of thousands of dollars, and in some cases, even more than one hundred thousand dollars.

The NSA requires out-of-network providers to inform patients in advance about estimated out-of-pocket costs for planned procedures and present the patient with a waiver and obtain the patient's consent. The IDR process is intended as a last resort when this process fails. However, our study found that certain providers have repeatedly brought cases for planned services performed at in-network facilities to the IDR process and have secured payments that are exceptionally high relative to several plausible benchmarks. The fact that certain categories of planned professional services are generating awards at least an order of magnitude higher than accepted in-network rates creates substantial payment incentives for providers to use the IDR process for these procedures; if the awards were close to in-network rates, as originally expected, there would not be a financial incentive to skip patient waiver and consent for balance billing in order to bring the case to the IDR process.

Conclusion

This analysis shows that, in the case of the most common planned procedures going through the IDR process under the NSA, awards are extremely high relative to several plausible payment benchmarks, with the median award exceeding 50 times the QPA. While the number of disputed claim lines related to these types of services is relatively small compared to disputes for emergency services, the costs stemming from these disputes are disproportionately high. Policy changes may be beneficial in ensuring that the NSA does not contribute to rising healthcare costs, particularly for planned out-of-network care that, in most cases (except for assistant surgeons when the primary surgeon was in-network), should not be a “surprise” for patients. Most of these awards are paid by self-funded employers rather than health plans, so any excess costs will ultimately be borne by employees and health plan members. Further research may explore recent trends in awards for other types of disputed care, including emergency and ancillary services, or may analyze the impact of the NSA on network formation, the cost of planned procedures, or the total cost of care.

Acknowledgments

The authors would like to thank the following individuals from Elevance Health for their contributions to this study: Annie Nayak for compiling the Transparency in Coverage data, Bradley Lerner for his assistance in describing policy implications, and Jennifer Kowalski for her support and insight throughout the study.

Supplementary material

Supplementary material is available at Health Affairs Scholar online.

Funding

This study was conducted as part of employment duties, as all authors are employed by Elevance Health. No additional funding was received.