Radiology scores over $1B through No Surprises Act’s independent dispute-resolution process
Radiology has scored approximately $1.03 billion through the No Surprises Act’s independent dispute resolution process, according to new research published Wednesday in Health Affairs.
This figure is part of an estimated $22.4 billion in total costs tied to the landmark legislation’s baseball-style arbitration process between 2023 and 2025. Also known as IDR, the No Surprises Act tasks outside third parties with helping resolve disputes between payers and providers over out-of-network care.
Of the total, about $15.6 billion represented payment amounts rewarded by arbitrators that exceeded in-network rates, Georgetown researchers estimated. Another $4.2 billion covered internal administrative costs, and $2.7 billion went toward IDR administrative and entity fees.
Researchers charge that these figures “dramatically exceed” previous estimates of $5 billion in total costs for the arbitration process between 2022 and 2024. Instead, total IDR costs were $16.6 billion in 2025 alone, an amount 3.5 times higher than 2024.
“These escalating costs are driven by the sheer volume of disputes (which rose by 77% from 2024 to 2025) and higher payment amounts (which rose by 264% from 2024 to 2025),” Jack Hoadley, PhD, and Kennah Watts, MSPH, both researchers with Georgetown University’s Center on Health Insurance Reforms, wrote Aug. 26. “Providers also continue to overwhelmingly prevail in the IDR process, winning about 85% of all IDR disputes in 2025 with a median award of more than four times the qualifying payment amount (QPA), which is defined as the median contracted in-network rate for care,” the two added later.
Like a previous Georgetown analysis on this topic, the IDR process continues to be “dominated by a handful of provider organizations, many of which are backed by private equity or have other conflicted profit interests.” Researchers cited Radiology Partners as No. 1 among these parties. The Nashville-based, investor-backed imaging group accounted for 30% of resolved disputes between 2023 and 2025. This was just ahead of HaloMD—a middleman organization that files disputes on behalf of radiologists and other providers—at No. 2, representing 27%. TeamHealth, a private equity-backed multispecialty group, came in at No. 3, representing 20% of resolved disputes, by filing organization.
Similarly, certain medical specialties accounted for the “vast majority” of IDR disputes, the authors noted. Between 2023 to 2025, emergency medicine accounted for 41% of disputes, ahead of radiology at No. 2 with 29%. In 2025, providers prevailed in about 85% of all disputes, similar to previous years but down slightly from the 88% seen in the second quarter of 2025 (the peak win rate to date). Of the five provider groups with the most disputes, four had a win rate above 90%. These included Radiology Partners (96%), Team Health (95%), practice management firm SCP Health (92%) and revenue cycle firm AGS Health (91%).
Georgetown experts noted that radiology scored median prevailing awards as a percent of the “qualifying payment amount” at about 468% in 2025. This was down from 559% in 2024 but up from the 409% figure seen in 2023. Other medical specialties earned much higher tallies, such as neurology (at 2,450% of the QPA), surgery (1,355%), and plastic surgery (3,239%).
“These wins represent billions of dollars in awards,” the author noted. For instance, from 2023 to 2025, total awards for surgery services added up to $3.8 billion. “This is especially notable,” the authors contend, given that the specialty only accounts for 5% of total disputes. Similarly, neurology accounted for 5% of disputes but totaled $2.02 billion in awards. In contrast, radiology had more disputes (about 23%), but awards only totaled $1.03 billion. Experts note this is likely attributable to radiology dealing in much smaller dollar amounts when compared to the big-ticket surgeries delivered by other specialties.
Given these “escalating” costs, Georgetown experts are suggesting possible congressional remedies to reverse the trend. Solutions could include replacing IDR with a payment standard to regulate what plans must pay out-of-network providers in disputes or changing how IDR entities balance the various factors considered in arbitration.
“While we have identified a range of options to build on and improve the NSA, policymakers may want to prioritize policies that more directly reduce the high costs of the IDR system by reforming the incentives that have resulted in high volume and high payment determinations,” Hoadley and Watts concluded. “These incentives and the resulting costs are undermining the NSA’s goal of cost containment and will likely contribute to higher costs for consumers and employers in the midst of a healthcare affordability crisis.”
Radiology response
Radiology stakeholders were quick to criticize the report and its conclusions on Wednesday.
“Once again, the folks at Georgetown University are carrying water for the health plans, so much so that this report reads as if it were from the America’s Health Insurance Plans (AHIP) itself,” Ed Gaines, VP of regulatory affairs for Zotec Partners and an expert on NSA issues, wrote on social media. “Facts are stubborn things so here we go…”
Gaines noted that about $2.5 billion of the total represented “clearly erroneous awards,” with an established federal process to reopen and correct them. Over one-third of 2025 awards were due to health plans refusing to make an offer and losing by default. And another nearly 10% represented instances where insurers offered $1 or less, according to Zotec’s research. Gaines also challenged estimates that $15 billion of the awards were above the median, in-network rate, based on the “qualifying payment amount.”
Providers have previously challenged this figure as being artificially low and not representative of reality. Recently, a court of appeals invalidated payers’ formula used to calculate the QPA, supporting providers’ concerns, Gaines noted.
“Are we surprised that the physician and hospital win rates are ~85%?” he wrote.
Radiology Associates of North Texas—a vocal critic of the IDR process—echoed Zotec’s sentiments. The Health Affairs analysis assumes the QPA is the correct market price and then labels every dollar above it “as a system cost,” notes RANT Chief Revenue Officer Dave Walker. However, the practice’s own analysis shows that Blue Cross Blue Shield of Texas has offered qualifying payment amounts at about 21% below in-network contracted rates. This fell between the 35th and 42nd percentile of the payer’s own published allowed amounts.
“That is not a median. If the benchmark starts too low, an award above QPA may be correcting the benchmark rather than inflating payment,” Walker told Radiology Business.
Radiology’s sizable dispute count also reflects high-volume, low-dollar services and “restrictive” batching rules, he added. Walker emphasized that award rulings are not the same as payments made—with the radiology practice receiving about $4.8 million in binding IDR determinations but collecting only about $1 million.
“Any fair assessment must examine QPA accuracy, negotiation conduct, batching, and payment compliance, not just award totals,” Walker charged.
The American College of Radiology—which recently met with CMS to voice these concerns—also challenged the Health Affairs article’s assertions. IDR case volumes and provider success rates are driven by insurers’ refusal to negotiate reasonable in-network rates. Payers also have avoided participating in open negotiations and refused to adjust their IDR offers.
“This pattern has continued despite arbiters and courts ruling that the insurers’ nontransparent qualifying payment amount-based offers do not reflect real-world medical practice,” ACR CEO Dana Smetherman, MD, MBA, MPH, said in a statement.
“Insurers are narrowing their networks, not providers,” she added. ACR gave the examples of Blue Cross Blue Shield of North Carolina, BCBS of Tennessee, and Cigna of TN, which all have cited the No Surprises Act when demanding providers accept “drastic reimbursement cuts” or risk termination of their contracts.
“As evidenced by court decisions, disputed claims arbitration results, and efforts by insurers to force radiologists out of their networks, healthcare providers are not the problem,” Smetherman said. “Policymakers should work with providers and insurers to consider relevant and verifiable data, guarantee adequate provider networks, and protect access to care by ensuring sensible, sustainable reimbursement.”
In its own statement, Radiology Partners cited a recent court ruling, with a federal judge questioning a payer’s “consistent practice of submitting lowball offers to out-of-network providers in an effort to maximize its profits.”
“The cost of healthcare is a legitimate and shared concern,” Rad Partners said in its statement. “However, with respect to the No Surprises Act, this [Health Affairs] analysis misses the mark by failing to address the underlying factors driving physicians to request arbitration in the first place, while relying on the qualifying payment amount as a proxy for fair commercial payment.”
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.