The Real Fix for Surprise Billing Requires Both Sides to Give

The No Surprises Act has done what it was designed to do: patients no longer get caught in the middle of out-of-network billing fights. That is a genuine win. But the law’s Independent Dispute Resolution (IDR) process has produced a Washington narrative that points reform in only one direction—and misses the fuller picture.  Clinicians and providers initiate the disputes; the top three filers accounted for 44 percent of all cases in 2025. Private equity-backed staffing companies dominate, winning roughly 90 percent of their arbitrations at payments averaging more than four times in-network rates. Volume is roughly 100 times the original projection, driving both higher-than-anticipated payments and ballooning friction costs. Insurer trade groups and employers have sold policymakers a narrative that these facts define a broken system being played by a few well-financed organizations.  But that is only one angle on the story.  Insurers alone calculate the Qualifying Payment Amount—the benchmark median in-network rate the arbitration system pivots around—using methodologies hidden from providers. The Fifth Circuit ruled in October 2024 (TMA III) that insurers may include “ghost rates”—contracted rates for services never actually performed by a given provider—in those calculations. The American Medical Association argued to that court that the below-market QPA  “has still become a lodestar for insurers, emboldening them to make extraordinarily low, take-it-or-leave-it offers,”  with physicians reporting rate reductions up to 50 percent anchored to it. About 20 percent of the time, insurers decline to participate in arbitration altogether, conceding to the provider’s offer—a tell that their own would not stand up.  The harder truth is that many services by medical practices never appear in IDR statistics at all. Smaller and independent medical groups can rarely afford the bureaucratic friction costs of IDR filings. Intermediaries representing these practices—not themselves private-equity affiliated, despite being among the largest filers—have arisen to serve them, complicating the standard “PE drives IDR” narrative. But practices that cannot afford even an intermediary accept the lowball or walk away. PE-backed firms have in-house infrastructure to contest every dispute.  So there are really conflicting narratives here, and they describe the same broken system. Insurers depress QPAs—as evidenced by provider win rates approaching 90 percent—and rely on friction to suppress challenge. PE-backed providers have the wherewithal to take insurers on, and the system rewards their scale and procedural sophistication, while many deserving of consideration are left out.  The Trump administration’s May 28, 2026 IDR Operations Rule did not address the underlying stalemate. It cut administrative fees, streamlined the portal, and tightened eligibility screening—important changes but not material to either side’s structural complaints. With the executive branch leaving the underlying machinery untouched, the case for legislative reform is strong.  Real reform must address the fundamental structural problem on both sides.  On the payer side, QPA calculations must become transparent. Clinicians and provider organizations should be able to audit how the QPA was constructed for their specialty or facility, with underlying data—including ghost-rate inclusions—made available. Insurers gaming the QPA, or defaulting in IDR above a threshold percentage, should face penalties. Methodology disputes need a streamlined administrative path, not the current four-year litigation cycle. And insurers who refuse to pay on lost decisions should be held accountable.  On the provider side, IDR should not be a license to stay out of network. The most effective reform reduces out-of-network care in the first place: hospitals contracting in-network should ensure their hospital-based specialists in anesthesia, radiology, pathology, and emergency medicine are in-network too. The out-of-network-physician-at-an-in-network-hospital loophole is what makes surprise billing so surprising in the first place. Organizations filing above a high threshold of disputes annually should disclose ownership, conflict structures, and private equity affiliations. Where charges appear excessive, audits and transparency should shed light on the data.  For the system, arbiter rationales should be published. IDR entities with financial ties to either side should be decertified. A safe-harbor “QPA-plus” payment band could resolve small-dollar disputes without arbitration.  The current debate forces a false choice between protecting patients and containing costs. Patients are already protected—the No Surprises Act took them out of the equation. The real question is how to contain costs while paying providers fairly. Today, neither happens. A high rate of appeals brings not just higher payments—as payer lowballing is exposed—but mounting friction costs, which flow into commercial premiums through employer plans. When QPAs sit below market and clinicians cannot afford to challenge them, small and independent practices accept the lowball and walk away. The system fails everyone.  Reform must recognize both behaviors and correct them, at a minimum with transparency, proportionate accountability, and arbiter criteria that reward fair offers rather than aggressive ones. It is overdue. 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