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Congress is weighing proposals to address problems in the No Surprises Act’s payment dispute system. One bill would replace arbitration with a benchmark payment; another would penalize insurers that fail to pay arbitration awards on time. The proposals face opposing views, and no resolution has been settled.
Congress is considering competing changes to the No Surprises Act as its payment dispute system faces a sharp rise in cases and court fights over unpaid awards. One proposal would eliminate independent dispute resolution and use a payment benchmark instead; another would impose penalties and reporting requirements when insurers do not pay arbitration awards on time.
The law, enacted at the end of 2020, protects patients from many unexpected out-of-network bills, including bills for emergency care at an in-network facility. When an insurer and an out-of-network provider cannot agree on payment, they can take the dispute to independent dispute resolution, or IDR. The dispute is between providers and insurers, rather than a process for patients to negotiate their own bills.
Jack Hoadley, a professor emeritus at Georgetown University’s Center on Health Insurance Reforms, told MedPage Today that Congress expected negotiations to resolve many cases, with arbitration used relatively infrequently. The law also created a qualifying payment amount (QPA), intended to approximate the median rate for comparable in-network care. Hoadley said federal court rulings rejected a presumption that arbitrators should default to the QPA and instead required them to consider other factors.
Hoadley said providers prevailed in about 85% of cases, a pattern he said encouraged higher payment requests. The government had estimated roughly 22,000 disputes a year; Hoadley said there were more than 4 million disputes in 2025. Those figures come from the report, and the provided material does not specify how the 2025 total was counted or whether it covers unique cases.
Rep. Frank Pallone (D-N.J.), the top Democrat on the House Energy and Commerce Committee, introduced a bill on Oct. 8 that would replace IDR with the QPA. A separate measure, introduced in September 2024 by Rep. Greg Murphy (R-N.C.), would require insurers that miss the 30-day deadline for paying awards to face steep penalties and would require more reporting on payment compliance.
Patients Protected, Payments Disputed
The dispute system affects how insurers and out-of-network providers settle payments after patients receive care protected by the law. For patients, the statute’s central protection against certain surprise bills remains distinct from the payment disagreements between insurers and providers. But the scale of IDR use raises questions about the cost and administration of the system, while arguments over award payment leave providers and insurers facing uncertainty.
The proposed bills point in different directions. Replacing arbitration with a benchmark could limit reliance on case-by-case decisions, while penalties for nonpayment would retain arbitration and seek to make its awards enforceable. Each approach could alter incentives for insurers and providers. The source report does not provide estimates of how either bill would affect health spending, premiums, or patient costs, so those consequences remain uncertain.
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How IDR Became a Congressional Issue
The No Surprises Act was passed at the end of 2020 to address bills patients could receive when out-of-network clinicians treated them at in-network facilities. The law established negotiation between insurers and providers, followed by IDR if talks fail. The QPA was meant to reflect a median in-network payment rate, but, according to Hoadley, litigation changed how arbitrators were instructed to weigh it.
Josh Hill, a partner at the Pietragallo Gordon Alfano Bosick & Raspanti law firm, told MedPage Today that the statute requires awards to be paid within 30 days, but does not clearly provide a way for providers to sue to collect them. Hill said two federal appeals courts have found providers lack that right, while a lower court reached the opposite conclusion. Cases are pending in Maryland and Virginia, and a further appeals court could eventually address the issue.
“Most people did expect arbitration to be used modestly in a relatively low number of cases.”
— Jack Hoadley, professor emeritus at Georgetown University’s Center on Health Insurance Reforms
Courts and Bills Leave Open Questions
Neither proposal is described as enacted, and the source material does not say when Congress might consider or vote on either measure. It also does not specify whether lawmakers are advancing other bills or negotiating a shared approach.
The legal question of whether providers can sue to collect unpaid awards remains unresolved across the courts described in the report. The pending cases in Maryland and Virginia could lead to another appeals court ruling, but their timing and outcomes are unknown. It is also unclear how much of the surge in disputes reflects providers’ requests, insurers’ responses, or repeat filings, and the report provides no verified estimate of the financial effect on patients or premiums.
Congressional and Court Decisions Ahead
The next steps are consideration of the competing bills and rulings in the pending cases. Congress would have to decide whether to retain arbitration with stronger payment enforcement, replace it with a benchmark, or pursue another change. Hoadley told MedPage Today that the problems are unlikely to be resolved through administrative action alone and that a congressional response may be needed.
A ruling from another appeals court could also deepen the disagreement over whether providers can sue to collect awards. If appellate courts reach conflicting conclusions, Hill said the Supreme Court could step in. No timetable or outcome for those court cases is established in the source material.
Key Questions
What is Congress considering?
One bill would replace independent dispute resolution with the qualifying payment amount as the payment benchmark. Another would penalize insurers that fail to pay arbitration awards within 30 days and require additional reporting.
Does the dispute process change the law’s patient protections?
The proposals described concern how insurers and out-of-network providers settle payments. The source report does not say that the existing patient protections have been repealed or changed.
Why are lawmakers looking at the arbitration system?
The report cites more than 4 million disputes in 2025, compared with a government estimate of about 22,000 disputes per year, and describes disagreements over award levels and insurers’ payment obligations.
Have the proposals become law?
No. The source describes bills under consideration, not enacted legislation. It gives no date for a congressional vote.
What is still being decided in court?
Courts have disagreed about whether providers can sue insurers to collect arbitration awards. Cases in Maryland and Virginia are pending, and their outcomes and timing remain unknown.
Source: medpagetoday.com
