The No Surprises Act (NSA) was designed to protect plan members from some but not all unexpected medical bills.
What the NSA did not do was protect employer-sponsored plans from escalating disputes over covered charges, procedural abuse and rising Independent Dispute Resolution (IDR) costs. Providers regularly claimed more than what the NSA allowed participants to be charged.
That reality was front and center during aequum’s recent webinar with The Granite List, Navigating the No Surprises Act: Prevent Ineligible Claims and Control IDR Costs. The discussion confirmed what many plan sponsors, brokers and consultants are already seeing, IDR is no longer a backstop. It is a growing source of financial and administrative risk that has directly influenced 2026 renewals.
Why This Matters Now
IDR volume continues to climb. More out-of-network claims are being pushed into this unique form of arbitration by hospitals, staffing companies and large provider groups.
For employer plans, the exposure is expanding on multiple fronts. Payment outcomes are unpredictable. Arbitration fees add friction to claim resolution. Administrative strain is growing for plans, TPAs and stop-loss partners. Forecasting and renewal planning are becoming harder, not easier.
Without stronger controls, NSA-related costs will not stay contained. They will show up in performance results, underwriting conversations and renewals.
How We Reached This Point
The NSA successfully limited balance billing for members but it shifted cost pressure onto employer plans. Participants were protected in three ways:
- First, out of network charges subject to the NSA qualified for better, in-network, point of purchase cost sharing (deductibles, copayments, coinsurance, out-of-pocket expense maximums),
- Second, the NSA limited covered expenses to the average network fees for the same services, and
- Third, the NSA precluded balance billing of participants for provider charges in excess of the covered expenses.
Bottom line, the NSA improved participant benefits.
It did so by shifting costs to the health plan, increasing the cost of coverage. Those increased costs may have been shouldered, initially, by the plan sponsor. But, over time, the resulting, ever-increasing cost of coverage increased both employee and employer contributions.
And, because participants are insulated from additional charges, many provider groups now treat IDR as a revenue strategy rather than a last resort. Procedural requirements are tested, ignored or strategically misused. When plans fail to enforce eligibility rules, providers win disputes that never should have qualified for arbitration in the first place.
Too often, plans pay IDR fees and settlements simply to move claims off the desk, even when the underlying case is procedurally defective.
And, why not? By paying the disputed charges, the costs are shouldered by the plan, which:
- Helps the claims administrator meet any metrics, and
- May result in higher fees where they are a function of the dollar amount of paid claims.
That dynamic drives cost creep and encourages repeat behavior.
The Hidden Cost Driver: Ineligible IDR Claims
One of the most important takeaways from the Granite List webinar was this, a meaningful portion of IDR cases are ineligible.
Common provider failures include missed deadlines, improper notice, incomplete or missing documentation, incorrect case types and failures during the open negotiation period. Each of these defects can disqualify a claim under NSA rules.
Every ineligible case that slips through increases plan spend and sets a precedent that providers remember. Over time, that precedent becomes a pattern.
What Plans Can Control Right Now
Plans cannot control provider tactics but they can control enforcement.
Procedural defense is the most effective leverage available. Every IDR filing should be reviewed for eligibility. Timelines and notice requirements must be enforced. Open negotiation should be fully documented. Claims that fail NSA prerequisites should be rejected, not negotiated.
Plan design is the second line of defense. Clear definitions for emergency services, allowable charges and out-of-network reimbursements reduce ambiguity.
Reference-Based Pricing provides a rational anchor. Plan language must support pricing logic consistently across the SPD, TPA workflows, stop-loss contracts, SBC and other participant communications.
Finally, documentation matters. Clean records, centralized tracking and defensible files built before arbitration begins materially change outcomes.
How aequum Helps Plans Take Control of NSA and IDR Exposure
This is where aequum operates.
aequum works with self-insured plans, brokers and consultants to defend plans procedurally and substantively under the No Surprises Act. Our role is not to manage disputes after the damage is done but to prevent unnecessary exposure before costs attach.
aequum supports plans by:
- Reviewing IDR filings for procedural eligibility and rejecting disputes that fail NSA requirements.
- Enforcing timelines, notice rules and open negotiation standards to exclude ineligible claims.
- Preserving plan rights and building defensible documentation from the earliest stages of a dispute.
- Identifying repeat provider behavior and patterns of procedural abuse.
- Strengthening plan language and reimbursement logic to support defensible outcomes.
- Supporting Reference-Based Pricing frameworks that hold-up under arbitration scrutiny.
- Coordinating with TPAs and stop-loss partners to eliminate gaps in compliance and reimbursement strategy.
By focusing on enforcement, documentation and plan defensibility, aequum helps plans reduce arbitration fees, limit inflated settlements and regain control of a process that has become increasingly unpredictable.
Reference-Based Pricing as a Stabilizing Shield
Reference-Based Pricing is not just a cost-containment tool. It is an anchor of claims defense.
Arbitrators consistently look for clear methodology and consistent logic. Plans with strong RBP frameworks have better leverage in negotiation and stronger positioning when disputes escalate. That leverage only holds when the plan document clearly supports the methodology.
aequum helps ensure RBP strategies are aligned with plan language so pricing decisions stand up under review.
What This Meant for 2026 Renewals
IDR activity from 2024 and 2025 definitely influenced plan renewals and stop-loss underwriting. Rising arbitration fees and unpredictable outcomes created drag on plan performance that underwriters factored into renewal pricing.
Plans that failed to control IDR exposure saw higher renewal pressure. Plans that enforced eligibility rules, maintained clean records and demonstrated disciplined dispute management were in a stronger position.
Renewals are not just about claims paid. They are about how well risk is controlled.
The Takeaway: Defense Starts Before Arbitration
The key message from the Granite List webinar is clear. Under the No Surprises Act, a plan’s greatest leverage is procedural.
A meaningful share of IDR cases should be excluded before they ever move forward. Strong plan design and solid documentation reduce exposure. Taking control of NSA compliance now prevents cost creep from rolling into 2026 and beyond.
aequum helps plans do exactly that, by defending plan rights, enforcing the rules providers rely on plans to ignore and keeping NSA-related costs from becoming a permanent line item.
If you weren’t able to join the live session, the full webinar recording is available on demand here.
Contact aequum today to understand where your plan is exposed or how much IDR activity is quietly driving cost. aequum can help you assess the risk and strengthen your defense.