No Surprises Act IDR rule 2026 with MGMA's Anders Gilberg

Federal regulators have finalized a long-awaited overhaul of the No Surprises Act's independent dispute resolution (IDR) process, and the headline change is a steep one: the administrative fee to initiate a dispute drops from $115 to $15 per party. The final rule, finalized in late May, also requires insurers to use standardized claim codes so practices can tell sooner whether a claim even qualifies for federal arbitration.

To unpack what the rule changes and what it leaves unresolved, Physicians Practice spoke with Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association (MGMA). Gilberg has spent years pressing regulators for a more accessible and transparent dispute process, and he sees the final rule as a meaningful, if incomplete, step.

The conversation has been edited for length and clarity.

What is the No Surprises Act IDR process, and why does it matter to practices?

Anders Gilberg: Medical practices face a lot of hurdles across different settings and with different payers. By way of background, the IDR rule, the dispute resolution rule, came out of the No Surprises Act, which I think was important legislation. It set up a process for situations where a patient goes to a hospital that is in network but is treated by a physician who is out of network, and then a dispute arises about how much to pay that physician. You don't want a situation where the patient is caught in the middle and gets fleeced.

It is also important coming on the heels of the Affordable Care Act, when a number of insurers made their provider panels so small that a lot of our members were effectively forced out of networks. So you end up with certain specialties, emergency medicine, radiology, pathology and anesthesia, where you have out-of-network physicians working in in-network hospitals. We are simply trying to make that process as streamlined as possible.

There are situations in the news, and I don't think they represent the majority, where the process has been abused. But that is not what MGMA is about. We want a fair, equitable process so physicians and medical practices taking care of patients in these settings get paid a fair and reasonable amount.

Does the final IDR rule give medical groups what they asked for?

Gilberg: It takes a couple of basic steps that I think are very important. It reduces the threshold for entry into the dispute resolution process. The administrative fee to initiate a dispute used to be $115 and now it is $15. That is a significant reduction, and for smaller practices it is a huge improvement. It is something we advocated for as part of this rule.

It also provides clarity on which claims are subject to the No Surprises Act. If a physician or practice submits a claim and gets a denial or a reduced payment on the back end, there will be a remittance advice code associated with that claim, coming from the payer, that indicates the claim is subject to the No Surprises Act. The practice can then avail itself of the process going forward.

What did the delay in finalizing the rule cost practices?

Gilberg: It certainly cost them money. With the fee at $115 and now reduced to $15, that is a significant difference. Beyond the cost, the delay meant the transparency issues I mentioned simply went unaddressed. There was ambiguity. The fees were exorbitant, and claims were being submitted that were not even eligible for the dispute resolution process. That confusion has now been alleviated, so this is a positive.

Where does administrative burden still remain in the IDR process?

Gilberg: There is more transparency now, with the claim adjustment reason codes and remittance advice remark codes, the CARC and RARC codes, that will transmit information back to providers about their eligibility for the process. But there is still additional burden on the back end. The process itself is cumbersome. There is a portal to submit information to, and there are additional reforms out there that could streamline and improve the submission process.

One of the bigger burdens is this: a lot of practices have gone through the 30-day negotiation and then the IDR process and ultimately won. Providers prevail more than 80 percent of the time in dispute resolution, only to receive no payment. So one issue still hanging out there, which is tied to legislation on the enforcement side of the No Surprises Act, is that providers go through the process, win or have their proposed payment upheld by the arbitration entity, and then the payer simply does not pay. On the back end, two things jump to mind: a more streamlined dispute resolution portal, and more accountability so that when a provider prevails in the IDR process they actually get paid in a timely manner.

Payers say the rule does not stop ineligible claims. What is MGMA's view?

Gilberg: I see the same articles you do, Keith, where there are a few outrageous situations, like a physician in Florida who submits a claim for hundreds of thousands of dollars and prevails. That is not where MGMA is on this. We are simply looking for a fair, equitable process.

If the payers are hiding behind the more egregious cases, I don't think they are really addressing the main issue, which is that providers still prevail the vast majority of the time. They could do more in the IDR process, including proposing payments closer to what they pay their in-network providers. So we would beg to differ in some of these situations. There are also a few cases of ownership, health systems and entities that are motivated more by profit, but those are the exception to the rule. This is an improvement, and we expect to see more improvements as the process goes along, hopefully including legislation to enforce timely payment on the payer side. MGMA is somewhere in the middle here. We are just trying to do what is right for practices that are often pushed out of network, or given no real opportunity for a fair contract with an insurer, and then have to go through this process to get paid when they treat an in-network patient.

Beyond the fee cut, how will the rule affect practices day to day?

Gilberg: I don't think this necessarily affects the majority of administrators. You are mostly dealing with the specialties I mentioned, emergency medicine, anesthesia and radiology, where in some cases you are seeing the patient and in some cases you are not, but you are contracted to provide care in a hospital and may be out of network in certain situations. For a typical administrator, I don't think they are going to use the IDR process as a common occurrence.

But for administrators in those specialties, the process is still frustrating, though it is now less costly. They should pay attention to the opportunity, given the reduced fees and the added clarity from insurers. When you get those remittance advice notices back on claims, you can more realistically consider appealing a denial because you know which claims are affected. There is a 30-day open negotiation period where you can reach out to the payer and hopefully agree on payment. If not, you go through the IDR process and get paid for the care you are delivering. As long as it is a fair and reasonable proposal, the baseball-style arbitration that IDR uses often rules in favor of the provider. Administrators should consider it carefully and know they have recourse when these claims are denied.

Is the rule a broader shift, and what should practices watch next?

Gilberg: I don't necessarily think this is a harbinger of things to come on other issues. There are a number of issues out there that are completely unrelated. But we appreciate that they have looked at, and are continuing to think about, providers and these processes. Hopefully, with some help on the legislative and enforcement side, there can be support for providers who win arbitration and still are not getting paid.