No Surprises Act: 3 Years In — What the Data Actually Shows

The No Surprises Act was supposed to end surprise medical billing in America. More than three years after it took effect on January 1, 2022, the law has saved patients billions of dollars—but it has also spawned a $5 billion arbitration industry dominated by private-equity-backed provider groups. Here's what the data actually shows.

The Scorecard: What's Working

By the most important measure—protecting patients from unexpected bills—the No Surprises Act (NSA) has been a clear success.

Surprise Bills Are Down Dramatically

An AHIP/BCBSA survey found that roughly 10 million surprise bills were averted in the first nine months of 2023 alone. That's 10 million times a patient would have previously opened an envelope and found a four- or five-figure bill from a doctor they never chose.

Out-of-Pocket Spending Has Fallen

A peer-reviewed study in the BMJ (Liu et al., 2025) found an 18% decline in out-of-pocket spending for privately insured adults receiving emergency care since the law took effect.

Researchers at Harvard and Mass General Brigham put a dollar figure on it: families in states gaining NSA protections saw average annual out-of-pocket spending fall from $3,674 to $2,922—a savings of $567 per year.

Most Claims Never Reach Arbitration

About 80% of claims eligible for NSA protections are resolved without going to the formal Independent Dispute Resolution (IDR) process. In most cases, providers accept the insurer's initial payment offer. This is the system working as intended—the law shifted the default from "bill the patient" to "negotiate with the insurer."

Public support reflects these results: an American Hospital Association poll found 88% approval for the law.

The Arbitration Explosion

The 20% of disputes that do go to arbitration have become a story unto themselves. When Congress passed the NSA, the Congressional Budget Office projected about 22,000 IDR disputes per year. The actual numbers have been orders of magnitude higher.

That's roughly 150 times what was projected. According to Healthcare Dive reporting on January 2026 CMS data, IDR entities have been clearing the backlog: they closed 1.35 million disputes in H1 2025 alone (a 48% increase), and 97% of all disputes are now either resolved or less than 30 days old.

Follow the Money: Who's Really Using IDR

The concentration of IDR filings reveals who is driving the arbitration boom—and it isn't small community hospitals.

Providers Win the Vast Majority of Disputes

According to Becker's Hospital Review, providers won 88% of IDR determinations in H1 2025, up from 85% in H2 2024. Median awards came in at 3.72 times the Qualifying Payment Amount (QPA), 2.04 times local in-network rates, and roughly 4.5 times Medicare rates.

A Handful of Groups Dominate

In H1 2025, just three entities—HaloMD, TeamHealth, and SCP Health—filed 44% of all IDR disputes. The top 10 filers accounted for 70% of the total. In 2023, TeamHealth alone represented 54% of dispute lines for the most common emergency room billing code.

HaloMD, a billing intermediary that files disputes on behalf of provider groups, saw its median disputed amount reach 934% of the QPA. Its win rate jumped from 17% to 84% between 2023 and 2024 as it refined its filings.

The Private Equity Connection

A PE Stakeholder investigation found that private equity firms back at least 5 of the 15 certified IDR entities—the very arbitrators deciding these disputes. The same PE firms that own the largest emergency staffing groups (the most frequent IDR filers) also have financial stakes in the arbitration entities that resolve the disputes.

An additional concern: roughly 20% of H1 2025 disputes were found to be ineligible for the IDR process altogether, and some surveys put that figure closer to 39%. These ineligible filings still consume administrative resources and drive up costs.

The Ground Ambulance Loophole

There is one major category of surprise bills the NSA does not cover: ground ambulances. When Congress drafted the law, ground ambulance providers were carved out at the last minute—leaving the single most common source of surprise medical transportation bills unaddressed.

The Numbers Are Stark

Approximately 85% of emergency ground ambulance rides are out-of-network. The average bill is around $450, but charges can reach thousands of dollars depending on distance and services provided.

States Are Starting to Act

In 2025, three states enacted new ground ambulance balance billing protections:

• Oregon — New protections for emergency ground ambulance patients
• New Hampshire — Balance billing restrictions for ground ambulance services
• Utah — Consumer protections for emergency ground transport

Colorado passed a ground ambulance protection bill with unanimous legislative support, only to have it vetoed by the governor. Only about 20 states have any form of ground ambulance balance billing protections.

The Commonwealth Fund maintains an interactive map tracking state-level ambulance protections, and the Harvard Petrie-Flom Center has called ground ambulances the last major gap in the NSA.

Enforcement

CMS has received more than 16,000 complaints related to NSA violations as of mid-2024 and has directed $11.3 million in restitution to consumers and providers. In September 2024, H.R. 9572 was introduced in Congress, proposing increased penalties for NSA violations.

What This Means for You

If You Receive a Surprise Medical Bill

If you received emergency care or were treated by an out-of-network provider at an in-network facility, you are very likely protected by the NSA. You should not be billed more than your in-network cost-sharing amount. If you receive a balance bill that you believe violates the law:

1. Do not pay immediately—verify whether the NSA applies to your situation
2. Contact your insurer and ask them to reprocess the claim under NSA protections
3. File a complaint with CMS if the provider or insurer is not complying
4. Call the CMS No Surprises Help Desk: 1-800-985-3059

If You Took a Ground Ambulance

Ground ambulance bills are not covered by the NSA. Check whether your state has its own protections. If not, you may still be able to negotiate the bill or apply for financial assistance from the ambulance provider.

For a full overview of your rights under this law, see our comprehensive No Surprises Act guide. If you've received a surprise bill, our balance billing guide explains how to dispute it step by step.

The Bottom Line

The No Surprises Act has delivered real, measurable benefits for patients. Millions of surprise bills have been prevented, and families are saving hundreds of dollars per year. Those are outcomes worth acknowledging.

But the law's arbitration system has been captured by a small number of private-equity-backed provider groups that are using it to extract payments far above in-network rates. The resulting $5+ billion in administrative costs is flowing into the same premium pool that consumers pay into. And the ground ambulance carve-out leaves millions of patients unprotected from the single most common surprise transportation bill.

The NSA is working for patients—but the system built around it is working even harder for the companies that have learned to exploit it.

Resources

• CMS — No Surprises Act Information
• CMS — IDR Reports and Data
• BMJ — Impact of the No Surprises Act on Out-of-Pocket Spending (Liu et al.)
• Mass General Brigham — NSA Reduced Patient Out-of-Pocket Spending
• Georgetown CHIR — The Substantial Costs of the NSA Arbitration Process
• KFF — Surprise Medical Bills
• Commonwealth Fund — State Ambulance Balance Billing Protections Map