The No Surprises Act (NSA) was designed to reduce unexpected medical bills and create a fair process for resolving out-of-network payment disputes. Central to that framework is the Independent Dispute Resolution (IDR) process, intended to bring balance between providers and payers.
What it did not anticipate was how that process could be used at scale to drive higher costs. The system designed to control costs is now being used to increase them.
For plan sponsors, that shift is where risk emerges.This is where aequum operates, stepping in to manage the risk when the system falls short of its intent.
The System is Under Pressure
A recent coalition of more than 60 employer groups, insurers and healthcare organizations has urged federal regulators to address what they describe as systemic manipulation of the IDR process. Their concerns are not theoretical. They are based on measurable trends that point to structural issues.
Dispute volume has far exceeded expectations. Federal regulators initially projected approximately 17,000 disputes annually. In practice, more than 3.3 million disputes were filed between mid-2022 and mid-2025.
At the same time, a small number of provider groups account for a disproportionate share of filings. In some cases, these entities are submitting charges significantly above typical benchmarks and prevailing reimbursement rates.
Outcomes are also trending upward. Providers are prevailing in a majority of disputes and payment determinations are often multiples of standard reference points such as the Qualifying Payment Amount (QPA) or Medicare-based rates.
The result is a process that, in certain cases, is no longer functioning as a neutral mechanism for resolving disputes but as a driver of increased cost.
The Enforcement Gap Behind the Trend
These developments point to a broader issue. The NSA established a dispute resolution framework but enforcement and oversight remain limited. Regulatory guidance continues to evolve. Rulemaking efforts have been delayed by ongoing litigation. Monitoring of arbitrator behavior and dispute patterns is inconsistent.
This creates an environment where:
• High-volume filings can proceed without early intervention.
• Eligibility questions may not be addressed before disputes escalate.
• Arbitrator decisions may vary widely across similar fact patterns.
• Cost increases are identified after they have already occurred.
Enforcement, in practice, remains reactive. That gap shifts responsibility downstream.
The Risk for Plan Sponsors
For self-insured employers, the implications are direct. Even when provider behavior is driving the issue, the responsibility does not shift. Plan sponsors are still expected to act as fiduciaries, managing plan assets responsibly, ensuring payments are defensible, overseeing vendors and maintaining NSA compliance.
The scale of current IDR activity only adds to that responsibility. High dispute volume, elevated payment outcomes and inconsistent decision-making are increasing both financial exposure and administrative burden. Plans that rely on standard processes or assume the system will correct itself may find themselves overpaying claims or defending decisions without the support needed to withstand scrutiny.
Compliance alone does not eliminate that exposure.
aequum Addresses the Risk the System Leaves Behind
As the gap between how the system is intended to work and how it actually functions continues to widen, plans need more than standard processes to stay protected. This is where aequum plays a critical role.
aequum operates at the intersection of dispute volume, pricing strategies and inconsistent enforcement. When the process starts to break down, aequum brings structure, oversight and defense to support plan sponsors.
aequum supports self-insured plans by:
• Identifying claims that may be ineligible for IDR before they turn into larger disputes.
• Evaluating billing patterns and provider behavior to identify high-volume or high-risk activity.
• Using claims data, transparency files and benchmarking to challenge inflated charges and support defensible payment decisions.
• Supporting IDR processes and timelines to help ensure submissions are complete and defensible.
• Defending against balance billing, excessive out-of-network charges and inappropriate collection efforts.
• Providing legal advocacy when disputes or provider behavior create added financial or fiduciary risk.
Taken together, these capabilities help plans reduce unnecessary costs, strengthen oversight and maintain a defensible position in a system that is still evolving.
The Need for Active Defense
The IDR process remains a central component of the NSA. It was designed to create fairness and predictability. In practice, variability in how it is used and applied has introduced new complexity.
For plan sponsors, the takeaway is not that the system is failing entirely but that it is incomplete.
• Disputes still require management.
• Decisions still require support.
• Oversight still requires action.
aequum helps ensure that plans are not reacting after costs have increased or disputes have escalated. It provides the structure, analysis and advocacy needed to manage IDR exposure in a system that is still evolving.
Now Is the Time for Employers to Stay Ahead of IDR Risk
The current environment calls for a closer evaluation of how IDR activity is affecting your plan. Understanding where disputes are originating, how they are being managed and whether payment outcomes are aligned with reasonable benchmarks is critical to maintaining control.
aequum equips plan sponsors to assess that exposure, strengthen oversight and defend plan decisions with confidence.
Contact aequum today to evaluate how your plan is managing IDR risk and where additional protection may be needed.