The number of disputes over certain healthcare payments under the No Surprises Act dispute resolution process rose 119% in one year. Private sector plans were involved in 520,000 disputes in the second quarter of 2025 compared with about 239,000 in the second quarter of 2024.
Likewise, the number of disputes involving fully insured employer plans increased 111%, reaching almost 44,000. The number of disputes involving self-insured employer plans increased 121%, reaching just over 195,000.
The disputes covered under the No Surprise Act include the following types of medical care:
- Emergency care received at out-of-network hospitals;
- Care from out-of-network providers while receiving care at in-network hospitals; and
- Air ambulance services.
Preliminary data also shows that when employers lose these disputes, they end up paying 20 to 40 times the typical in-network rate for care. The final payment resulting from the dispute resolution process is a percentage of the qualifying payment amount (QPA), or the amount that typically would be paid for services to an in-network provider. While some records maintained by the Centers for Medicare & Medicaid Services (CMS) lacked information, a BenefitsPRO analysis examined a sample of one million records from the second quarter of 2025. The analysis found that, in cases where full payment amounts were disclosed, fully insured employer plans paid about 173% of the QPA, or about 1.73 times what they would have paid in-network providers for the same services. Meanwhile, self-funded health plans that won their disputes paid about 185% of the QPA. However, when self-insured plans lost, the paid amounts averaged 23 times the QPA, and when fully insured plans lost, the paid amounts averaged 44 times the QPA.
Congress created the No Surprises Act to help insured patients avoid costly, unanticipated out-of-network charges for some services by removing them from the equation altogether. Instead, the plan and the health insurance company participate in an alternative dispute resolution system to reach a final payment amount. However, plans are complaining about their high rate of losses in the dispute resolution system and about large final payment amounts that dwarf the QPA. As a result, some benefits and patient advocacy groups have united to lobby Congress to prevent further cost increases.
HBL has experience in all areas of benefits and employment law, offering a comprehensive solution to all your business benefits and HR/employment needs. We help ensure you are in compliance with the complex requirements of ERISA and the IRS code, as well as those laws that impact you and your employees. Together, we reduce your exposure to potential legal or financial penalties. Learn more by calling 470-571-1007.
