Congressional Budget Office contends provider wins undermining No Surprises Act

The Congressional Budget Office contends provider wins are undermining the No Surprises Act, calling for additional research to better understand failures of implementing the landmark legislation. 

Five years ago, the CBO had estimated the NSA would help reduce prices insurers pay to radiologists and other providers who had high rates of surprise billing. In turn, the office anticipated that the premiums insurers charge for commercial plans would fall. 

However, evidence suggests “the law might not have the effects that CBO anticipated,” the office said in a blog post published June 15.

“Although prices for some services that had high rates of surprise billing before the law's enactment have declined, several published reports indicate that providers are winning more than 8 in 10 IDR cases,” the office reported. It noted that physicians are “being awarded payments that are much higher than expected, particularly in certain geographic areas. CBO is therefore seeking research that evaluates the law's effects on healthcare prices and network participation.”

The Centers for Medicare & Medicaid Services previously reported in January that radiologists and other providers won about 88% of payment disputes with insurers in the first half of 2025. Emergency medicine accounted for the largest share of payment determinations at 45%, followed by radiology at 19%. Another analysis estimated that Radiology Partners was scoring wins at more than 600% of the initial “qualifying payment amount” offer. (RP noted that this figure is not a reliable proxy for in-network rates, while also adding that radiology typically deals in low-dollar claims, with these percentages adding up to small amounts.)

The CBO said evidence suggests provider participation in networks has increased while inflation-adjusted prices for impacted services have generally declined. However, evidence about changes to in- and out-of-network payments “remain limited,” with claims data generally lagging behind the delivery of care. Meanwhile, research on the NSA’s arbitration process suggests that negotiated prices might increase over time. 

Administrative costs associated with the independent dispute resolution system also have exceeded the CBO’s projections. Recent estimates indicate that insurers and providers spent almost $900 million in fees associated with arbitration through 2024. These fees were greater than anticipated due to the high number of cases, with CMS increasing charges to cover the unexpected volume. 

“Although evidence suggests that prices for services affected by the No Surprises Act may have initially decreased, arbitration outcomes could lead to higher prices over time,” the CBO noted. “If providers can systematically secure large payments through the IDR process, they have an incentive to remain out of network or demand higher in-network rates.”

The office said it will continue to monitor outcomes from the No Surprises Act as it prepares cost estimates and projections for Congress. It believes the agency could benefit from research that relies on more recent data to better understand trends related to network participation, prices and ownership structure. Current claims data used in existing studies only goes through 2023, “when patterns from arbitration were only beginning to develop.” 

“CBO would welcome research about how healthcare markets continue to evolve in the wake of the law,” Tamara Hayford, the deputy director of health analysis at the Congressional Budget Office, and co-authors concluded. “Early evidence suggests that large organizations dominate arbitration activity, potentially disadvantaging smaller providers and encouraging consolidation. Continued analysis of market structure and competition will be critical for understanding the law's long-term effects.”