No Surprises Act Billing Disputes: What the 2026 Data Shows

For patients, the No Surprises Act did what it promised. The four-figure bill from the anesthesiologist nobody chose, the emergency room physician who turned out to be a contractor, the radiologist reading a scan in another state — those bills largely stopped arriving on January 1, 2022. What almost nobody predicted was the machinery that would grow in their place: an arbitration system that has now processed more than six million billing disputes between doctors and insurers, at a cost one Georgetown University team puts at $22.4 billion.

The law did not eliminate the argument over what an out-of-network doctor should be paid. It removed the patient from it. Everything that has happened since is a fight between providers and health plans over money the patient no longer owes — a fight that has turned out to be far larger, far more lucrative and far more contested than Congress imagined.

What the law fixed

Start with the part that worked, because it is easy to lose in the argument that follows. An AHIP and Blue Cross Blue Shield Association survey estimated that roughly 10 million surprise bills were averted in the first nine months of 2023 alone. Each one is a household that did not open an envelope and find a charge it had no way to anticipate and no way to refuse.

The spending data agrees. A peer-reviewed study in the BMJ (Liu et al., 2025) found an 18 percent decline in out-of-pocket spending among privately insured adults who received emergency care after the law took effect. Researchers at Harvard and Mass General Brigham attached a dollar figure to the same effect: in states that gained protections under the federal law, average annual out-of-pocket spending fell from $3,674 to $2,922, a saving of $567 a year.

For scale, the Inflation Reduction Act's Medicare Part D changes — the decade's best-known consumer drug-pricing reform — were projected by the Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation to save about $400 a year for each enrollee who sees any savings at all, or $7.4 billion spread across 18.7 million people in 2025. The populations are different and the two numbers should not be added together or ranked against each other too confidently. But they are the same order of magnitude, which is more than most health legislation can claim.

The arbitration explosion

When Congress wrote the law, it built an escape valve: if a health plan and an out-of-network provider cannot agree on a price, either can push the claim into a federal arbitration process, formally called Independent Dispute Resolution. Each side submits an offer, a certified arbitrator picks one, and the loser pays the fee. The Congressional Budget Office projected the valve would be used about 22,000 times a year.

The cumulative total passed 6.3 million on May 31, 2026 — 6,336,032 filings in a little over four years. The ladder underneath it is the part worth reading twice: even the program's quietest stretch ran about 39 times the projection, 2025 ran 116 times it, and 2026 is on pace for roughly 167 times. The comparison that circulates most often, dividing the entire cumulative total by the annual projection, overstates it; the honest version is still extraordinary.

The backlog that defined the program's first two years, on the other hand, has largely been worked off. Arbitrators had closed 5,862,819 of those disputes by May 31, 2026, and in July they closed 371,715 against 394,140 new filings, roughly keeping pace with intake. According to Healthcare Dive's analysis of the federal data, about 62 percent of payment determinations in the second half of 2025 came within 30 business days, up from 37 percent in the first half.

Who is filing all these disputes

The volume is not coming from patients, and it is not spread across the health system. In the second half of 2025, three filers — the billing intermediary HaloMD and the physician staffing companies TeamHealth and SCP Health — accounted for about 38 percent of all disputes, down from roughly 44 percent in the first half of the year but still an extraordinary concentration for a federal process open to every provider in the country.

They are winning. Providers or their representatives prevailed in about 85 percent of cases decided in the second half of 2025, and the winning offer exceeded the insurer's benchmark rate in roughly 87 percent of payment determinations. Earlier data pointed the same way: Becker's Hospital Review reported that providers won 88 percent of determinations in the first half of 2025, with median awards at 3.72 times the qualifying payment amount, 2.04 times local in-network rates and roughly 4.5 times Medicare.

A large share of what gets filed should never have been filed at all. The proportion of disputes found eligible for the process has fallen from about 69 percent in the first half of 2022 to 19 percent in the second half of 2025, according to the same analysis of federal data. Ineligible filings still consume arbitrator time, and someone pays for that time.

Who owns the arbitrators is its own question. A Private Equity Stakeholder Project investigation found that private equity firms back at least five of the 15 certified dispute resolution entities — the arbitrators themselves — while the same class of investor owns the emergency staffing groups that file most often.

What the fighting costs

In August 2026, Jack Hoadley and Kennah Watts of Georgetown's Center on Health Insurance Reforms published the first serious attempt to total it up, in Health Affairs Forefront. Their estimate for 2022 through 2025 is $22.4 billion: $15.6 billion in award amounts above what in-network rates would have paid, $4.2 billion in internal administrative costs absorbed by plans and providers, and $2.7 billion in filing and arbitrator fees, as published — the rounded components add to slightly more than the rounded total.

The trend inside that number matters more than the number. Costs in 2025 alone came to $16.6 billion, roughly 3.5 times the 2024 figure, as dispute volume rose 77 percent and the payment amounts at stake rose 264 percent. Median awards in 2025 ran more than four times the qualifying payment amount, and in some specialties the multiples were extreme — median awards in neurology and plastic surgery ranged from 24 to 30 times the benchmark.

These are not costs a patient sees on a statement; they arrive as premium. The New York State Department of Civil Service reported more than $200 million in additional claim payments from arbitration for the state employee plan, which it called a primary contributor to a nearly 10 percent premium increase. A UnitedHealthcare official described the process as driving a 2 to 6 percent incremental increase in total premium expense for its commercial business.

The doctors' groups reject the framing. A day after the Georgetown analysis appeared, the American College of Emergency Physicians, the American College of Radiology and the American Society of Anesthesiologists issued a joint response arguing that the entire estimate rests on treating the qualifying payment amount — a benchmark the insurer itself calculates, using data physicians cannot audit — as if it were a fair price. Anything paid above it is then counted as a cost. If the benchmark is too low, the "excess" is not excess at all.

The benchmark under the whole system is now in doubt

That argument is no longer only rhetorical. On August 11, 2026, the full United States Court of Appeals for the Fifth Circuit ruled en banc in Texas Medical Association v. Tyler and struck down key parts of the federal rules governing how the qualifying payment amount is calculated. Insurers may no longer include so-called ghost rates — contracted rates for services a provider never actually performed — and may no longer exclude bonus, incentive and risk-sharing payments from the arithmetic. Both changes push the benchmark up.

The practical effect is that the number at the center of six million disputes is being recalculated, upward, by court order. Every projection of what arbitration costs, including the $22.4 billion, was built on the old method.

The ambulance that isn't covered

One category of surprise bill was left out of the law entirely. Ground ambulances were carved out late in the drafting, which means the single most common way an American receives an out-of-network bill during an emergency is the one the No Surprises Act does not touch. Air ambulances are covered; the ride to the hospital is not. About 60 percent of ground ambulance transports for privately insured patients involve an out-of-network provider, according to FAIR Health data cited in our guide to ambulance costs.

States have begun filling the gap one legislature at a time. As of 2026, 22 states have enacted ground ambulance balance billing protections of their own, according to the Commonwealth Fund, five of them in 2025 alone: North Dakota, Utah, New Hampshire, Oregon and West Virginia. A federal advisory committee delivered recommendations for a national fix in August 2024, and Congress has not acted on them. The Petrie-Flom Center at Harvard Law School calls ground ambulances the last major gap in the law, and no federal fix is close.

What patients can do

If you were treated in an emergency, or by an out-of-network clinician at an in-network hospital or surgery center, the law almost certainly covers you, and you cannot be charged more than your plan's in-network cost sharing. A bill that says otherwise is worth challenging before it is worth paying. Ask your insurer to reprocess the claim under the No Surprises Act; that alone resolves a large share of these bills, because they are frequently processing errors rather than defiance. If the provider or the plan will not comply, the federal complaint process is real and staffed — the No Surprises Help Desk is 1-800-985-3059.

Two things are worth knowing before you call. The arbitration described above is not available to you; it is a process between providers and plans, and a patient cannot file. And if the bill is from a ground ambulance company, the federal protections do not apply at all — check whether your state has its own, and if it does not, treat the bill as negotiable, because it is.

For the full set of rights the law creates, see our No Surprises Act guide; for the mechanics of pushing back on a bill that violates it, our balance billing guide walks through the dispute step by step.

How Health Bill Central can help

A bill that violates the No Surprises Act looks like every other bill. Upload it and we will itemize what you are being charged, flag the line items that should have been covered at in-network rates, and draft the letter to send to the provider or the plan.

Sources

Dispute volumes and closure figures come from the Departments' Federal IDR bi-monthly reports and public use files, read as of the reports dated May 31 and July 31, 2026. The cost estimate is Jack Hoadley and Kennah Watts, "Spending On IDR Process Pushes No Surprises Act Costs To More Than $22.4 Billion Over Just Four Years", Health Affairs Forefront, August 26, 2026, with the specialty societies' objection to its benchmark published the following day. Filer concentration, win rates and eligibility rates are from Healthcare Dive and Becker's Hospital Review; arbitrator ownership from the Private Equity Stakeholder Project; patient savings from Liu et al. in the BMJ and Mass General Brigham. Background on surprise billing generally is collected by KFF. Related reading on this site: what a good faith estimate must contain and what an emergency room visit actually costs.