New Elevance Health Public Policy Institute Study Examines Payment Disputes for Planned Procedures Under the No Surprises Act

Key Terms

no surprises act regulatory

A federal law that protects patients from unexpected out-of-network medical bills by limiting what providers and insurers can charge when care is received without a clear cost agreement. For investors, it changes how hospitals, physician groups, insurers and medical billing firms set prices, collect revenue and resolve payment disputes—similar to changing the rules of a game, it can shift revenue streams, margins and legal risk across the healthcare sector.

independent dispute resolution regulatory

An independent dispute resolution is a process where a neutral third party — such as an outside mediator, arbitrator, or panel — reviews and decides on conflicts between a company and its stakeholders (investors, customers, regulators) instead of the company handling it internally. For investors this matters because it can produce a fairer, clearer outcome, reduce the risk of biased or prolonged internal fights, and protect value by resolving issues more quickly and transparently — like bringing in an impartial referee to settle a contested call.

out-of-network regulatory

Out-of-network describes a healthcare provider or service that does not have a payment agreement with a patient’s health insurer, so the insurer may cover less of the cost or none at all and the patient can face higher bills. For investors, out-of-network status influences how much hospitals, clinics and insurers collect, affects patient choice and volume, and creates revenue uncertainty and regulatory risk—like buying from a store that doesn’t accept your discount card, which can be pricier and less predictable.

medicare regulatory

Medicare is a large government-run health insurance program that primarily covers people aged 65 and older and certain younger people with disabilities. For investors it matters because Medicare acts like a huge customer and rule-maker for hospitals, drugmakers and medical-device companies—its coverage decisions, payment rates and regulatory policies can change demand, revenue and profit margins across the healthcare sector, similar to how a major client or regulator can shape a business’s prospects.

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Research finds arbitration awards for certain planned procedures are often far higher than typical in-network payment rates

INDIANAPOLIS--(BUSINESS WIRE)-- The No Surprises Act was created to protect patients from unexpected medical bills. While those patient protections are working, new research from the Elevance Health Public Policy Institute suggests that the law's payment dispute process is producing unexpected results for some planned medical procedures.

The findings come as federal IDR volume has grown far beyond initial projections, raising concerns that a process intended as a limited payment-dispute backstop is increasingly contributing to higher out-of-network costs.

The study examined more than 7,300 payment disputes involving procedures and services that are typically scheduled in advance, such as spine surgery, plastic surgery, colonoscopy, and other scheduled services. These procedures qualified for the dispute resolution process because they were performed at in-network facilities by out-of-network providers. Researchers found that providers won nearly 90 percent of disputed claim lines and that payments awarded through the federal Independent Dispute Resolution (IDR) process were often tens to hundreds of times higher than typical in-network commercial rates and Medicare payment rates.

"The No Surprises Act was designed to protect patients from unexpected medical bills, not to increase healthcare costs," said Catherine Gaffigan, MD, president, health solutions at Elevance Health. "Our Public Policy Institute’s research raises serious concerns that the dispute resolution process is being used for certain scheduled services in ways that diverge from the law's original intent. When the system is exploited, the result is higher costs for employers and families who ultimately bear the burden through higher premiums and healthcare expenses. Preserving patient protections requires ensuring that the dispute resolution process is used appropriately and functions as Congress intended."

The No Surprises Act took effect in 2022 and protects patients from many surprise medical bills when they receive out-of-network care. When insurers and providers cannot agree on payment for services covered by the law, either side can bring the dispute to an independent arbitrator.

When most people think about surprise medical bills, they think about emergency care or situations where a patient has little control over who provides treatment. This study focused on a different set of cases: planned procedures scheduled in advance with an out-of-network provider at an in-network facility, which later became the subject of payment disputes.

Among the study's findings:

• Providers won 89.5 percent of disputed claim lines included in the analysis.
• The average IDR award for the procedures studied was nearly $40,000, compared with average benchmark rates based on in-network commercial payment or Medicare prices that ranged from approximately $645 to $1,600.
• The median IDR award was more than 50 times the median in-network contracted rate for the same service in the same market.
• Awards for these procedures increased 43 percent between 2024 and 2025.

Researchers also found that out of all disputed services, many of the highest-dollar disputes involved procedures that patients typically schedule in advance, including certain spine and plastic surgery services.

"We found that payments awarded through the arbitration process for these planned procedures were usually substantially higher than what clinicians are typically paid for similar services in-network," said Aliza Gordon, Director of Research at the Elevance Health Public Policy Institute and co-author of the study. "These findings raise important questions about how the process is functioning and suggest that additional safeguards are needed to help keep healthcare costs affordable."

The No Surprises Act has largely achieved its primary goal of protecting patients from surprise bills. However, researchers say policymakers should consider changes to the law to ensure the dispute resolution process remains focused on the situations it was originally designed to address while continuing to protect patients.

“This research confirms what ERIC's member companies are seeing firsthand: the IDR process has drifted far from its original purpose," said James Gelfand, President and CEO, The ERISA Industry Committee (ERIC). "When arbitration awards for planned, scheduled procedures come in at fifty times the market rate, that's not a dispute resolution system working as intended; that's a cost-inflation mechanism. Employers and working families are paying for these outrageous arbitration awards through higher premiums and reduced benefits. Congress designed the No Surprises Act to protect patients and lower costs, and those protections must stay in place, but policymakers need to act now to stop the explosive costs IDR is creating."

The full report, The No Surprises Act: Independent Dispute Resolution for Planned Procedures, is available at https://www.elevancehealth.com/public-policy-institute/no-surprises-act-independent-dispute-resolution-for-planned-procedures.

About Elevance Health, Inc.

Elevance Health is a lifetime, trusted health partner whose purpose is to improve the health of humanity. The company supports consumers, families, and communities across the entire healthcare journey – connecting them to the care, support, and resources they need to lead better lives. Elevance Health’s companies serve over 105 million consumers through a diverse portfolio of industry-leading medical, pharmacy, behavioral, clinical, and complex care solutions. For more information, please visit www.elevancehealth.com or follow us @ElevanceHealth on X and Elevance Health on LinkedIn.

About Elevance Health Public Policy Institute

The Public Policy Institute (PPI) was established to share data and insights that inform public policy and shape the healthcare programs of the future. PPI strives to be an objective and credible contributor to healthcare transformation through the publication of policy-relevant data analysis, timely research, and insights from Elevance Health’s innovative programs. For more information, please visit www.elevancehealthppi.com or follow Elevance Health PPI on LinkedIn.

View source version on businesswire.com: https://www.businesswire.com/news/home/20260625057504/en/

Media Contact:
Janey Kiryluik
janey.kiryluik@elevancehealth.com

Source: Elevance Health, Inc.