The No Surprises Act appears to be accomplishing its central patient-protection objective: patients are less exposed to surprise out-of-network bills. Its broader cost-saving assumptions are much less certain. Federal data now show an IDR system with far more disputes than anticipated, providers prevailing in most arbitrations, and many awards materially above the payment benchmarks expected when the statute was enacted.
The original economic premise was lower negotiated prices
When Congress enacted the No Surprises Act, the Congressional Budget Office expected the statute to reduce both in-network and out-of-network prices for services associated with surprise billing. CBO projected that the resulting lower prices would reduce commercial premiums by roughly one percent and federal deficits by about $17 billion over 2021–2030.
In June 2026, CBO called for new research because emerging evidence “might not have” the effects originally anticipated. CBO reported that providers were winning more than eight in ten IDR cases, awards were often substantially higher than expected, and administrative costs had also exceeded projections.
IDR results have often exceeded in-network benchmarks
A 2026 Congressional Research Service analysis examined emergency-service disputes from 14 states resolved during the first half of 2024. Across that sample, the median prevailing offer was approximately 312 percent of the median in-network rate, and more than 95 percent of prevailing offers exceeded the median in-network rate.
Those figures do not mean providers are legally entitled to their full billed charges. They are not. The No Surprises Act expressly bars IDR entities from considering a provider’s usual and customary charges or billed charges in selecting an offer. The concern is different: awards can still land far above the qualifying payment amount (“QPA”) and negotiated in-network benchmarks even though billed charges themselves are excluded.
Read the CRS analysis of Federal IDR outcomes.
Court decisions limited agency efforts to privilege the QPA
Early agency rules attempted to make the QPA the dominant reference point in IDR. Providers challenged those rules, and federal courts repeatedly held that the agencies had imposed weighting requirements not found in the statute.
In Texas Medical Association v. HHS, 110 F.4th 762 (5th Cir. 2024), the Fifth Circuit upheld vacatur of rules that effectively placed extra weight on the QPA relative to the other statutory factors Congress directed arbitrators to consider.
Read the 2024 Fifth Circuit decision.
The litigation has continued into the mechanics of QPA calculation. In an en banc 2026 decision, the Fifth Circuit held that the agencies could not require inclusion of non-negotiated “ghost rates” for services a provider did not actually furnish and rejected the exclusion of certain bonus and incentive payments from the QPA calculation. The court treated the QPA as a statutory benchmark whose calculation must track Congress’s text—not as an agency-created price control.
Read the 2026 en banc decision.
Federal reform has focused on operations and enforcement
The Departments issued final Federal IDR operations rules in 2026 aimed at eligibility determinations, required disclosures, batching, payment administration, and lower process costs. Among other changes, the administrative fee was reduced to $15 per party for disputes initiated on or after June 11, 2026.
Read CMS’s summary of the 2026 IDR reforms.
Congress also has considered enforcement legislation. The bipartisan No Surprises Act Enforcement Act, introduced as H.R. 4710 and S. 2420, would strengthen penalties and compliance mechanisms for violations of the Act’s payment and balance-billing requirements. Those proposals focus principally on enforcement; they do not simply reinstate the QPA-weighting rules invalidated by the courts.
Read S. 2420, the No Surprises Act Enforcement Act.
Practical implications
The emerging picture is mixed. Patient protections appear to be functioning. But the IDR system has developed differently from early projections, and the relationship among QPA calculations, arbitration outcomes, network contracting, and premiums remains an active empirical and legal question.
For plans and providers, the result is a reimbursement environment in which QPA methodology, IDR evidence, eligibility, batching, payment deadlines, and network negotiations can matter as much as the underlying billed amount.
This article is for general informational purposes only and is not legal advice. Federal IDR rules, agency guidance, and related litigation continue to develop.