Researchers at the Georgetown University Center on Health Insurance Reforms published their analysis of the costs incurred by the No Surprises Act (NSA) independent dispute resolution (IDR) process, putting the total at $22.4B through 2025. Most of these costs come from the payment awards that reached nearly $13B in 2025, 85 percent of which went to providers. The authors argue that, although the NSA succeeded at its primary goal of protecting consumers from surprise out-of-network medical bills, it has failed to reduce premiums because a few private equity (PE)-backed provider organizations exploited design flaws in the IDR process: “providers have a clear incentive to keep filing disputes and to ask for higher and higher amounts [because] there is no evidence that there is any ceiling on the amount requested by providers that are deemed by IDR entities to be the superior offer.” Two PE-backed physician roll-ups, Radiology Partners and TeamHealth, and a middleman organization filing disputes on behalf of providers, HaloMD, were responsible for over 75 percent of dispute filings in 2025.
 
Some provider groups have pushed back against this study’s findings, particularly its $22B headline figure, on the grounds that the “qualifying payment amount” (QPA) used by the authors to calculate how much excess spending the payment awards generated is itself flawed, gamed by insurers to be artificially low. However, the authors noted that doubling the QPA in their estimates would only reduce 2025’s excess spending by about $2B. The Trump administration recently finalized changes that should reduce the volume of IDR disputes by formalizing communication during open negotiations, but it does not have a mechanism to reduce the ever-growing size of the awards. Without further changes, this cadre of PE-backed specialty groups and middlemen will continue to exploit the system, driving up costs for employers and unions, resulting in higher premiums for the commercially insured. Notably, PE-backed groups like these were also responsible for the surprise-billing exploits that prompted the No Surprises Act's passage in the first place.