Radiology fires back at report claiming providers ‘gaming’ No Surprises Act

The imaging community is firing back at a high-profile report claiming radiologists and other providers are “gaming” the No Surprises Act. 

Published in the Wall Street Journal on July 22, the report was the first to share fresh data from the landmark law, meant to protect patients from unexpected medical bills. The Centers for Medicare & Medicaid Services estimates providers scored about $14.85 billion in payments last year through the NSA’s arbitration process, used to settle disputes between docs and insurers. 

This represents more than triple the total for 2024, with radiologists, anesthesiologists and emergency medicine physicians some of the biggest winners. 

“It’s shocking that it’s rising so fast,” Jack Hoadley, a research professor emeritus at Georgetown University’s Center on Health Insurance Reforms, told the news outlet. 

According to the Journal, CMS believes that the No Surprises Act system is “being gamed to get higher prices” for providers. The agency is now “actively working to clean it up,” according to the report, which did not disclose potential remedies. CMS officially released the latest No Surprises Act data on July 22, after the report was published, detailing arbitration results through the second half of 2025. 

The findings show that independent arbitrators handled an “increasingly large volume of disputes,” submitted to the federal portal. Despite “continuing complexity” in determining whether payment quarrels were eligible for the process, there was “substantial improvement” in throughput, dispute disclosures and timeliness. 

More on the data

Between July and December, payers and providers initiated nearly 1.4 million payment disputes through the federal portal, up 16% compared to the beginning half of last year. Providers initiated the most disputes, at 76%. Across over 1.1 million payment determinations made in the back half of 2025, emergency medicine accounted for the largest share (52%), followed by radiology (15%). 

Radiology Partners accounted for about 5% of all initiated disputes, or a total of nearly 70,000 in the second half of 2025, placing the practice fifth on the provider list. Meanwhile, UnitedHealthcare was the payer most involved in disputes, accounting for about one-quarter or over 338,429 quarrels initiated. 

In the fourth quarter of last year, radiology providers earned median prevailing offers at about 398% of the “qualifying payment amount,” down from 473% in Q3. Also known as the QPA, this represents a median of an insurance plans’ contracted in-network rate. Altogether, radiology saw about 171,000 payment determinations in the second half of 2025, representing 418,000 items or services. 

Insurance companies claim these awards are pushing up medical spending and premiums for employers, the Wall Street Journal notes. Meanwhile, providers counter that insurers are not always paying the amounts arbitrators award, while the QPA is often an artificially low figure. 

“In a sign of the provider groups’ success in winning large payouts, the 2025 total was more than six times the amount that would have resulted based on estimates that are supposed to represent typical in-network payment rates, according to the Journal’s analysis,” the report notes. 

Federal officials previously estimated there would be around 22,000 claims per year handled by arbitrators. However, there were 1.4 million filed in the first five months of 2026. WSJ criticized these figures in a corresponding editorial, calling the high volume of provider wins a “racket,” noting that radiologists and other docs have prevailed in 90% of cases while wining payments 3 to 9 times in-network rates. 

“Insurers wanted Congress to require arbitrators to peg payments to out-of-network providers to their in-network rates. Provider groups called this unfair,” the Wall Street Journal wrote in its editorial, which is heavily slanted toward the payer side. “Congress finally attached the No Surprises Act to its December 2020 COVID spending splurge. Providers won. Insurers and their customers lost. The legislation ended surprise bills but swelled costs for insurers, which are now being passed along in higher premiums.”

Radiology responds

Radiology stakeholders criticized the WSJ and its coverage on Tuesday. Radiology Partners, the largest practice in the U.S., contends the rising volume of disputes is the result of payer’s “frequent unwillingness” to “contract fairly or act responsibly in out of network situations” 

In drafting the No Surprises Act, Congress established a neutral, baseball-style arbitration process to “protect practice stability and preserve patients’ access to care.” 

“The data shows that this process is necessary,” Malea Reising, MS, VP of strategic communications for Nashville, Tennessee-based Rad Partners, told Radiology Business. “If QPAs were audited, transparent and reflective of actual market rates, as Congress intended, far fewer claims would be submitted for arbitration. Policymakers should focus on improving transparency and reducing the need for disputes by addressing the financial incentive for insurers to push providers out of network and underpay for care.”

Meanwhile, Radiology Associates of North Texas—a vocal proponent of addressing shortfalls in the NSA—said the Wall Street Journal raises “important questions” about the independent dispute resolution process. However, focusing only on the total amount of awards does not explain why so many claims are entering arbitration, nor why insurers are consistently refusing to pay legally binding awards. 

Based on the practice’s analysis of CMS data and its own experience, “the system often fails before arbitration even starts,” Dave Walker, RANT’s chief revenue officer, told Radiology Business. The qualifying payment amount—intended to serve as a lawful benchmark amount for claims, based on median, inflation-adjusted rates from 2019—is often “materially below prevailing market reimbursement levels.” 

RANT’s experience with Blue Cross Blue Shield of Texas “illustrates the issue,” Walker contends. The qualifying payment amount applied by the insurer has been about 21% below RANT’s prior contracted rates, falling between the 35th and 42nd percentile of the payer’s published rates. In prior congressional estimates, RANT calculated that the appropriate 2019-baseline qualifying payment amount would be about 235% of Medicare. However, Blue Cross Blue Shield paid 150%—“a benchmark substantially below the NSA’s QPA formula and RANT’s historic commercial collections.” 

“That starting point matters,” said Walker. “If the insurer anchors payment to a below-market QPA and then does not engage meaningfully in open negotiation, arbitration becomes the default pathway rather than the last resort Congress intended. In our experience, carriers often offer either the original QPA amount or no meaningful increase during open negotiation. In some cases, the offer is effectively zero. That leaves providers with little practical alternatives other than pursuing IDR.”

He estimates the Fort Worth-based practice—the largest independent imaging group in the U.S.—has submitted over 100,000 radiology services through the federal open-negotiation process. This is meant to give payers and providers a chance to hash things out before needing to enter arbitration. However, Blue Cross Blue Shield Texas has refused to meaningfully participate. 

“We do not want arbitration to be the default,” Walker said. “We want fair contracts, predictable reimbursement, and negotiated resolutions. But negotiated resolution requires both sides to engage in good faith on a level playing field.”

When a payer offers a below-market benchmark and refuses to openly negotiate, independent arbitrators often are left in a challenging position. 

“Under those circumstances, it should not be surprising that providers often prevail,” Walker said. “That outcome does not prove the system is being gamed by providers; it may instead highlight flaws in QPA methodology, open negotiation behavior, payment compliance, and the cynical tactics of commercial payers.”

He also stressed the important distinction between awards issued and awards paid. While Radiology Associates of North Texas has won nearly $5 million through the federal IDR process, it has only received roughly $1 million of those awarded amounts. This is tied to “tens of thousands” of claims submitted. 

“The remaining balance is not a theoretical dispute over policy. These are claims that completed the federal arbitration process and received binding determinations,” Walker said. 

And this issue is not exclusive to radiology, he added. An Emergency Department Practice Management Association survey found that across nearly 650,000 IDR cases won by providers last year, health plans failed to comply with payment requirements 50% of the time. This totaled approximately $245 million in unpaid obligations. 

“The answer is not to weaken the patient's protections in the No Surprises Act or to undermine independent dispute resolution,” Walker added. “The answer is enforcement. Effective enforcement would allow regulators to distinguish legitimate disputes from bad-faith behavior, create incentives for early resolution, reduce administrative cost, and ensure that final determinations are honored.”

The Radiology Business Management Association—which hosted a panel discussion about the NSA with Rad Partners and RANT at its recent annual meeting—echoed these sentiments. RBMA highlighted a “concerning lack of transparency” around QPA calculations, with radiology groups having little ability to verify how insurers calculated them. 

Plus, while many of the NSA discussions focus on big-ticket, expensive surgeries, radiology is different, the association added. The specialty often deals in high-volume, low-dollar services, such as routine X-rays billed at $50. 

“It is therefore misleading to draw broad conclusions about radiology based on aggregate arbitration statistics that are heavily influenced by other specialties and service categories,” Linda Wilgus, RBMA co-executive director, said in an email to Radiology Business. 

She believes the high volume of disputes should prompt policymakers to examine whether the NSA’s processes are functioning as intended. Climbing IDR case volumes, she believes, indicate “insurers and providers are struggling to reach reasonable network agreements,” along with the reality that “benchmark payment amounts do not reflect marketplace realities.” 

“Simply attributing higher arbitration awards to providers ‘gaming the system’ risks overlooking underlying concerns about payment adequacy and the accuracy of insurer-calculated benchmarks,” Wilgus added.