The Litigation Gravity Well Around the No Surprises Act and Why Angels Should Care More Than They Think

Disclaimer: These views are my own and do not reflect those of my employer.

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Table of contents

1. Abstract

2. How We Got Pulled Into This IDR Reality

3. The Arbitrator Eligibility Fights Getting Real

4. When Batching Becomes a Litigation Weapon

5. The Administrative Fee Problem Nobody Saw Coming

6. Why Providers Are Using the Fifth Circuit as a Strategic Amplifier

7. Payers Start Feeling the Shift in IDR Loss Ratios

Abstract

1. Providers have flooded courts in the past few months with petitions aimed at arbitrator eligibility rules, batching mechanics, and administrative fee structures.

2. These fights stem from earlier Fifth Circuit rulings that reshaped how QPA can influence independent dispute resolution outcomes.

3. The newer wave of petitions is reactive to late 2025 IDR denials, which providers argue were inconsistent with prior case law and improperly constrained what counts as a similar claim.

4. The litigation pressure is increasing loss ratios for payers in IDR, particularly in specialties with asymmetric negotiating leverage like radiology, anesthesia, and neonatology.

5. Provider groups are now using litigation itself as a kind of stress test on the government’s QPA framework, creating a feedback loop that affects contracting, pricing, and the economics of health tech companies supporting either side.

How We Got Pulled Into This IDR Reality

If someone had asked ten years ago whether arbitration rules written for emergency and post stabilization care would become one of the most litigated topics in the entire US healthcare system, most people would have assumed the question was a joke. Yet here we are, in a universe where everyone from massive physician staffing companies to independent anesthesiology groups to small regional radiology practices is filing challenges over the little procedural gears that drive the independent dispute resolution pathway. The past three months alone saw a concentrated burst of petitions that read like a tug-of-war between providers and CMS over how the arbitration machinery is supposed to work. The background here is that the No Surprises Act was supposed to be a neat policy fix that would stop patients from getting slammed with out of network medical bills. The law ended up creating a new battlefield where providers and payers both argue they are the real victims of regulatory improvisation. Providers point at CMS and say the arbitrators are being told to view the QPA as a gravitational center despite court rulings that told the agency it overstepped. Payers argue that providers are turning IDR into a revenue engine and filing disputes in bulk the moment contract negotiations stall. Somewhere in the middle are arbitrators who were probably expecting a pretty quiet existence and instead found themselves refereeing some of the most adversarial economic fights in healthcare. The fun twist is that the court system has become a kind of second arbitration venue, one level up, where the disputes are no longer over individual payment amounts but over the rules that govern the entire pathway.

The Arbitrator Eligibility Fights Getting Real