The No Surprises Act was built for the patient who shows up in the ER at 2am with no choice about who treats them. That was the problem Congress solved in 2022.

What happened next was predictable. Providers figured out that an out-of-network surgeon performing a scheduled procedure at an in-network facility triggers the same IDR eligibility. Breast reductions generating ninety thousand dollar IDR awards against eleven hundred in Medicare reimbursement. Not illegal. Not ineligible. A loophole- and the insurance companies are not wrong that it is being exploited.

But here is where it gets ugly.

Elevance Health- Anthem’s parent- publicly called IDR a “back-door payment channel” for nonemergent procedures.¹ Their VP of health economics said it on the record. Their response was not to fix the system. Their response was to stop paying. Anthem failed to even participate in more than 30% of IDR disputes in 2024- just did not show up, took the default judgment, and still did not pay.² They implemented a 10% payment penalty on hospitals using out-of-network providers effective January 2026 across 11 states.³ They sued 11 Prime Healthcare hospitals in California alleging $15 million in improper awards.⁴ Blue Cross sued HaloMD under RICO.⁵

Elevance’s public position: “The NSA is not viable as currently applied.”

That is not a company planning to comply. That is a company announcing- through lawsuits and policy- that federal IDR awards are paper they do not intend to honor.

And the courts back them up. The Fifth Circuit ruled in June 2025 that the No Surprises Act does not give providers a private right of action to enforce IDR awards.⁶ The Supreme Court denied cert in January 2026.⁷ In the Second Circuit- New York- the Southern District dismissed a $3 million enforcement suit brought by a plastic surgery group against Cigna.⁸ Same specialty. Same jurisdiction.

CMS enforcement? 1.3% complaint resolution rate.⁹ Decorative.

The No Surprises Enforcement Act- triple damages for non-payment- was introduced in Congress.¹⁴ The insurance industry has effectively killed it. $130 million in lobbying in 2025 alone.¹⁰ The bill has not moved.

Initially, provider losses in federal IDR were substantial. That has changed- win rates have climbed, awards have grown. But the current legal and political environment may very well push decisions back toward the QPA even before Congress acts. The insurance lobby is not waiting for legislation. They are reshaping the battlefield through the courts, through policy, and through sheer refusal to pay- and there is no mechanism to stop them. And for providers building practices around scheduled procedure IDR- there is a real question whether the process will even remain available for non-emergency claims at all. Elevance is already lobbying Congress to clarify that elective services should not qualify for IDR.¹⁵ If that happens, practices structured entirely around this loophole lose not just their collection mechanism- they lose their eligibility.

Meanwhile providers are filing by the millions. Over 2 million disputes in 2025 alone- CMS originally projected 17,000 per year. The top three filing entities account for 44% of all disputes nationally.¹¹ An AFHC survey of 48,000 physicians found that in 2022, 52% of IDR awards went completely unpaid. By 2023 that dropped to 22%- still one in five wins that never converts to cash.¹² EDPMA found that 52% of the time, payers do not even acknowledge an IDR has been filed.¹³

The providers chasing federal IDR are in a worse position than before they started. They win on paper. They staff up. They celebrate. They spend money they have not collected. And the check never comes- because there is no mechanism to make it come without an act of Congress that the insurance lobby is spending nine figures to block.

The folly is not just the non-payment. It is structuring an entire practice around federal IDR- building overhead, hiring staff, making financial commitments based on awards that may never convert to cash. The practice itself becomes a mirage. Revenue on paper. Nothing in the bank.

Now Compare That to New York State IDR

No 30-business-day open negotiation period. No 4-business-day initiation window. No 30-day entity selection. No months-long decision timeline. The system is straightforward- file, submit, decision.

If you know how to properly frame the special circumstances in a full submission- not a form with a number on it, but a documented package signed by an attorney- you win. My win rate on NY State IDR is 99%.

And when you win- you collect. Every time.

With an open line of communication, DFS enforces all awards and leaves zero wins unpaid. Thirty days to pay. Not a suggestion- a regulatory mandate from a state agency with actual teeth. I have had insurance companies apologize to me in writing.

The folly is chasing federal IDR without a collection mechanism. Any shop can win an IDR. The question every provider should be asking is not “can you win?”- it is “can you collect?”

And the most pertinent question is- is your practice built on a mirage? And can you sleep at night?

Results vary by claim and jurisdiction. Prior outcomes do not guarantee future results.