Every dispute, driven to an award.
The No Surprises Act (NSA), effective January 2022, took the patient out of the middle of out-of-network billing fights. When an insurer and a provider can't agree on what an out-of-network service is worth, they no longer bill the patient the difference — they go to arbitration. This is the pipeline that produces the record NSA Tracker reads.
What the Act protects
For emergency care, air ambulance transport, and out-of-network clinicians working at in-network facilities, the patient owes only their normal in-network cost share. The balance is settled between the insurer and the provider — and if they can't settle it themselves, a neutral arbitrator decides. Crucially, the arbitration outcome can never raise the patient's cost share. The award moves money between insurer and provider only.
How one bill travels
The claim is flagged
An out-of-network line item eligible for federal IDR is identified and marked as a No Surprises Act claim rather than an ordinary denial — the starting point for everything that follows.
Open negotiation — 30 days
Before anyone can file for arbitration, the parties get a 30-business-day open-negotiation window to reach a number on their own. Most disputes that settle, settle here and never appear in the arbitration file.
IDR is initiated on the federal portal
If negotiation fails, either side initiates Independent Dispute Resolution through the CMS federal portal. This is the moment a dispute enters the public record.
A certified arbitrator is selected
The parties either agree on a certified IDR entity (IDRE) or the government assigns one. The arbitrator is neutral and certified by CMS; there are only a few dozen of them handling the entire country.
Both sides submit a single offer
Arbitration is “baseball style” — each party submits one dollar figure, and the arbitrator must pick one of the two. There is no splitting the difference, which pushes both sides toward a defensible number.
The offers are weighed against the QPA
The anchor is the Qualifying Payment Amount (QPA) — the insurer's median contracted rate for that service in that market. The arbitrator starts from the QPA and weighs additional statutory factors before choosing the winning offer.
The award is binding — and paid in 30 business days
The losing side has no appeal on the merits, and payment is due within 30 business days. The award is the end of the dispute; the payment is the end of the story.
The QPA is set by the insurer, and every insurer sets it differently. Reading who wins, and by how far each payer's QPA sits from the local market, is much of what NSA Tracker exists to show.