The No Surprises Act at a Crossroads: From Protection to Performance

The No Surprises Act at a Crossroads: From Protection to Performance

Sean Crandell

General Manager, Claims Intelligence Solutions, Claritev

The No Surprises Act (NSA) has made a meaningful difference for patients by removing them from many out-of-network billing disputes. Early into policy implementation, there was also a positive impact on employer costs. But with the volume burden that has entered the system, eventually those administrative expenses move through the industry, and trickle back downstream.

The payment-resolution infrastructure behind the No Surprises Act protections operates at a scale far beyond what policymakers originally envisioned. Over the past few years, it has created growing operational and financial pressure - driving $5B in costs - that are affecting predictability and alignment across the healthcare ecosystem.

The No Surprises Act Independent Dispute Resolution Operations Final Rule (CMS-9897-F) fundamentally shifts administration from a largely manual process to a more standardized, auditable and technology-enabled operating model. However, implementation will take time and the full impact on dispute volumes remains to be seen.

This change emphasizes that the No Surprises Act regulatory environment is dynamic and will remain complex.

If rising administrative burden and complexities from the NSA are not addressed, healthcare affordability will be impacted, driving the cost of care up for the exact population the policy was created to protect.

Why This Matters Now

5 million and counting

Since April 2022, over 5.1M disputes have been initiated, and the numbers continue to climb. CMS reported 248,452 independent dispute resolution (IDR) initiations in January 2026 alone, underscoring that NSA volume remains high even as throughput improves.

The NSA final rule creates new compliance and operational obligations. But it also provides opportunities to reduce administrative burden, improve dispute management efficiency, and strengthen visibility into out-of-network payment dynamics.

Organizations that proactively adapt their claims, payment, and dispute management processes will be better positioned to navigate the evolving regulatory environment while supporting more predictable and streamlined dispute resolution outcomes.

Preventable Costs Hurt Everyone

47% ineligible volume

Claritev client data shows 47% of IDR submissions were deemed ineligible in 2025 - a signal that preventable cost is entering the system upstream.

The analysis also flagged more than 5,500 claim lines where provider offers exceeded billed charges, contributing to more than $600,000 in additional IDR administrative fees and more than $3.5 million in additional IDR entity fees.

Is AI the Answer?

As healthcare assesses the right solution for both evolving No Surprise state and federal NSA policy adherence it's a combination of operational processes, industry expertise, and responsible AI that will accurately and effectively make an impact.

Healthcare needs trust, proven impact, and reliability.

A smart take: the issue is not only AI explainability, but whether the underlying cost and payment signals from AI are reliable enough to support decisions. In this case, it's bigger than adopting AI. Looking at the complexities of healthcare holistically and implementing the right strategic approach accordingly.

The Changes Needed

To achieve positive change and fairness across the NSA landscape, rather than shifting the burden from one organization to another, will require action from everyone.

In evaluating and streamlining the financial workflows that connect the healthcare ecosystem, this is how true value can be achieved. Intentional shifts towards reducing administrative burden and removing those costs from the equation.

Steps for Healthcare Leaders to Reduce Independent Dispute Resolution Friction:

1. Combine technology and industry expertise to turn NSA operations into a repeatable, data-driven process

1. Embed responsible AI into workflows to streamline and inform operations

1. Use segment-driven analytics and market expertise to improve negotiations

1. Tighten eligibility, timing, and operational controls to avoid downstream costs

1. Leverage additional benchmarks such as price transparency data to help establish fair and reasonable reimbursement recommendations

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