The No Surprises Act (NSA) was intended to protect patients from surprise medical bills and keep them out of payment disputes between providers and health plans. By many accounts, that objective has been achieved. During a recent industry webinar, provider-side attorney James Greenspan stated that “the overarching goal of the law seems to have been accomplished, which was keeping the patients out of the middle.”
However, the NSA IDR process failed to achieve the second, equally important goal, to facilitate resolution of the actual billing dispute.
As provider-side organizations devote more resources to pursuing payment disputes through the Independent Dispute Resolution (IDR) process, they are consistently achieving success in payouts.
Payers face growing pressure to defend reimbursement decisions, manage administrative burden and protect plan assets. aequum offers sophisticated payer support in resolving IDR disputes – helping self-insured employers, TPAs, stop-loss carriers and plan sponsors navigate the increasingly complex reimbursement challenges created by the NSA.
A New Type of NSA Participant
Gottlieb & Greenspan is a New Jersey-based healthcare reimbursement law firm focused on arbitration and litigation involving provider reimbursement disputes. According to publicly available information, the firm’s practice provides robust services to support the filing of NSA IDR cases on behalf of physician groups, ambulatory surgery centers and hospital systems. The significance is not the firm itself but what its services reveal about the broader reimbursement landscape.
Organizations are building dedicated practices around NSA reimbursement advocacy. They are developing expertise in arbitration procedures, eligibility standards, forum selection and payment disputes. Participation across thousands of disputes creates institutional knowledge that can be applied repeatedly across future cases. Over time, that experience becomes a strategic advantage.
The IDR System Has Reached Scale
In a Centers for Medicare and Medicaid Services report covering the first six months of 2025, the numbers show that more than 1.37 million disputes were closed during 2024. By July 2025, dispute closures exceeded new dispute initiations as backlog reduction efforts continued.
Reducing the backlog may be a losing battle. Between January 1, 2025, and June 30, 2025, disputing parties initiated 1,186,812 disputes through the federal IDR portal, 39% more than the last six months of 2024 (853,374 disputes)
Clearly, this is no niche process. The federal IDR system has become a significant component of the healthcare reimbursement structure.
As activity has increased, repeat participants have become more influential. The same report identifies a relatively small group of organizations responsible for a significant share of dispute activity, including HaloMD, Radiology Partners, Team Health, SCP Health and Gottlieb & Greenspan.
That concentration matters. Organizations that participate in thousands of disputes gain experience, become familiar with procedural requirements, understand documentation standards and develop strategies. Over time, that experience becomes a competitive advantage.
Why Self-Insured Plans Should Pay Attention
The growth of highly experienced provider-side advocates changes the environment in which reimbursement disputes occur. Organizations that participate in thousands of disputes understand procedural requirements, eligibility standards, forum selection rules and documentation expectations. The challenge for plans is recognizing that reimbursement disputes increasingly involve sophisticated repeat participants with substantial experience navigating the system.
The webinar comments attributed to Greenspan provide a good example. His discussion focused on identifying self-insured plans, selecting the correct dispute forum and understanding circumstances under which scheduled procedures may qualify for NSA protections. These are detailed procedural issues that can materially affect IDR outcomes.
Complexity Creates Risk
Federal regulators have already acknowledged the operational challenges associated with managing large volumes of disputes. The Federal Independent Dispute Resolution Operations Final Rule introduced changes intended to improve communication between parties, streamline eligibility reviews, clarify timelines and reduce submissions of ineligible disputes into the IDR process.
Those changes reflect a simple reality, highlighting the need for greater screening of eligibility as well as confirming that the administration of reimbursement disputes has become increasingly complex.
For self-insured employers, that complexity carries operational and financial implications. Every dispute consumes time and resources to properly support reimbursement determinations, and to ensure procedural requirements are carefully followed/enforced.
How aequum Helps Plans Respond
The emergence of specialized provider-side advocacy reinforces the need for equally sophisticated plan-side support. Self-insured plans must balance compliance obligations, reimbursement strategy, fiduciary responsibilities and dispute management while navigating a regulatory environment that continues to evolve.
aequum helps plans address these challenges through advocacy, regulatory expertise, dispute management and data-driven analysis. By helping plans evaluate exposure, support reimbursement determinations and identify emerging risks, aequum provides the oversight and expertise needed to operate effectively in a complex IDR environment.
As reimbursement disputes become more specialized and more frequent, plans need more than a reactive approach. They need a strategy for protecting plan assets and managing risk.
The Stakes Extend Beyond Administration
The implications extend beyond administration. Providers, facilities and air ambulance providers continue to prevail in approximately 85% of IDR determinations. Median prevailing offers also continue to exceed Qualifying Payment Amounts (QPAs) across several high-volume specialties, including emergency department services, radiology and anesthesia.
These findings reinforce the importance of active reimbursement oversight and disciplined dispute management. For plan sponsors, reimbursement disputes are not simply administrative events. They are financial, compliance and fiduciary events.
The Bigger Takeaway
The growth of firms like Gottlieb & Greenspan is not significant because of any one organization. It is significant because it reflects a broader shift within the NSA dispute landscape. Provider-side advocacy has become increasingly specialized, experienced and active.
Self-insured plans should view this evolution as a signal. The reimbursement environment continues to become more sophisticated and success increasingly depends on consistent oversight, defensible reimbursement strategies, operational discipline and experienced advocacy.
Plans that proactively assess and challenge eligibility, manage disputes, monitor exposure and strengthen reimbursement governance will be better positioned to control costs, protect plan assets and fulfill their fiduciary responsibilities.
Contact us today to learn how aequum can help your organization navigate reimbursement disputes, strengthen IDR strategy and protect plan assets in an increasingly complex NSA environment.