Practices win most billing disputes. Getting paid is another story.

The federal government's updated independent dispute resolution rule makes it cheaper and clearer for medical practices to contest out-of-network payment disputes, but winning arbitration still doesn't guarantee a check.

Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association, sat down with Physicians Practice to break down what the rule changes, where the administrative burden remains and what practices should watch on the regulatory calendar for the rest of 2026. The following transcript has been edited for length and clarity.

Physicians Practice: Hey there, folks. Today we're talking to Anders Gilberg, senior vice president of government affairs for MGMA. How are you doing, Anders?

Anders Gilberg: I'm great, Keith. How are you?

Physicians Practice: Not too bad. Today we're talking about the new IDR rules. Give me a quick rundown of what's come out of the regulatory space on that.

Gilberg: Medical practices face a lot of different hurdles in a variety of settings with different payers. To recap, although many of your listeners already know much of this, the IDR rule, the dispute resolution rule, came out of the No Surprises Act, which was important legislation and a regulatory scheme that set up a process for situations where a patient goes to a hospital, maybe the hospital is in network, but the physician is out of network, and disputes arise about how much to pay the physician. Obviously, you don't want to create a situation in which the patient is in the middle and getting fleeced. It's important legislation, but it also came on the heels of the Affordable Care Act, where a number of insurers made their provider panels so small that a lot of our members were forced out of networks as networks got smaller. So you have certain specialties, like emergency medicine, radiology, pathology and anesthesia, where you have out-of-network physicians and in-network hospitals, and we're just trying to make the process as streamlined as possible. There are situations in the news, I don't think they're the majority, where there have been abuses of the process, but that's not what MGMA is all about. We just want to create a fair, equitable process for physicians and medical practices taking care of patients in settings like this, so they get paid a fair and reasonable amount.

Physicians Practice: You all have been pushing for action on this for a couple of years. Does the final version give medical groups what they've been asking for?

Gilberg: It takes a couple of basic steps that I think are very important, and 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's $15. That is a significant reduction, and for smaller practices that is a huge improvement, and something we advocated for as part of this rule. It also provides clarity in terms of which claims are subject to the No Surprises Act. If a physician or a practice submits a claim and gets a denial or reduced payment on the back end, there would be a remittance advice code associated with that claim from the payer indicating it is subject to the No Surprises Act, and they could then avail themselves of the process going forward.

Physicians Practice: This has been under regulatory review for more than two years. What did that delay cost practices in the meantime?

Gilberg: It certainly cost them money, with the fees at $115 before being reduced down to $15. Those delays also didn't address the transparency issues I talked about. There was ambiguity created. Not only were the fees exorbitant, but claims were submitted that were not eligible for the dispute resolution process. That confusion and some of that ambiguity has now been alleviated, so that's positive.

Physicians Practice: A lot of the provisions in this rule are framed as providing relief from regulatory burden. Where is the administrative burden still sitting for groups in this process?

Gilberg: There's going to be more transparency with these CARC and RARC codes, as they're called, that will transmit information back to providers to reflect their eligibility for the process. There still is additional burden on the back end. The process itself is cumbersome. There is a portal to submit information to, and there can be additional reforms to help streamline the submission process. One of the big burdens is that a lot of medical practices have gone through the 30-day negotiation and the IDR process and ultimately won, providers win over 80 percent of the time in dispute resolution, only to not receive any payment. One of the things hanging out there is legislation dealing with No Surprises enforcement, because providers going through the process and having their suggested payment upheld by the arbitration entities are still not getting paid because the payers just don't pay up. So on the back end, two things jump to mind: a streamlined dispute resolution portal, and more accountability to make sure that when a provider, medical practice or doctor has prevailed in the IDR process, they get paid in a timely manner.

Physicians Practice: Speaking of payers, they're saying this rule doesn't do enough to stop ineligible claims. What's MGMA's view on that?

Gilberg: I see the same articles you do, Keith, where you have a few outrageous situations, like one physician in Florida who submits a claim for hundreds of thousands of dollars and prevails. That's not where MGMA is on this. We are simply looking for a fair, equitable process. If the payers are just hiding behind these more egregious cases, I don't think they're really addressing the main issue, which is that providers still prevail the vast majority of the time. They could do more to step up in the IDR process and propose payments on their end that are closer to what an in-network payment is for their in-network providers. We would beg to differ in some of these situations, but they often highlight the most egregious examples. There are also situations that fall outside our own purview, where you have a few cases of ownership of health systems, entities and practices that are motivated more by profit, but those are the exception to the rule. This is an improvement, and we're going to continue to see improvements as this process goes along, hopefully with passage of legislation to enforce the timeliness of payment on the payer side. All in all, MGMA is somewhere in the middle here. We're just trying to do what's right for practices that oftentimes are pushed out of network or provided no opportunity to have a fair contract with an insurer, and then are forced to go through this process to get paid if they are treating an in-network patient.

Physicians Practice: For an administrator who's just reading this news, the biggest change is probably the fee reduction down to $15. Besides that, what do you think would be the biggest thing that affects their day-to-day operations?

Gilberg: I don't think this necessarily affects the majority of administrators. You're dealing mostly with some of the specialties I mentioned: emergency medicine, anesthesia, radiology, where in some cases you're seeing the patients and sometimes you're not, but you're contracted to provide care in a hospital, maybe in certain situations out of network. For a typical administrator, I don't think they're going to avail themselves of the IDR process as a common situation. But for administrators in those specialties, the process is still frustrating, but it's now less costly. They should pay attention to the opportunity now that the fees are reduced and the insurers are going to provide a little more clarity. 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. The process is relatively clear. There's a 30-day open negotiation process where you can reach out to the payer and hopefully agree on some payment, but if not, then go through the IDR process and get paid for the care you're delivering. As long as it's a fair and reasonable proposal in the baseball-style arbitration process that IDR provides, the arbiters often rule in favor of the provider. An administrator should consider carefully, but know that they have recourse now when these claims are denied.

Physicians Practice: Now comes my favorite part of all interviews with you, Anders. I want you to get in the head of the administration. Is this rule a sign of a broader shift in how it's approaching the No Surprises Act, and what should practices watch for next?

Gilberg: I don't necessarily think this is a harbinger of things to come on different issues. There are a number of issues out there completely unrelated to this, but we do appreciate the fact that they've looked at and are continuing to think about providers in these processes. Hopefully, with a little help on the legislative and enforcement side, there can be some support for those providers that have won arbitration and just aren't getting paid. Setting this aside, there are a number of rules I would flag for your audience and MGMA members in general. We have two HIPAA rules pending, one dealing with privacy and one dealing with security, that may come out in the coming months. The physician fee schedule will come out around July 30, so we're going to see a lot of things impacting payment. Those will be some major potential milestones in the regulatory process for the rest of the year as we get up toward the election. Then, after the election, there are a lot of unresolved issues that need to be resolved before 2027, so there will be a lame-duck session, hopefully, to pass different things. We're back to dealing with geographic price indices and different kinds of payment issues that expire at the end of this year, which will be important to typical administrators, physicians and MGMA members. It's going to be a busy summer, so stay tuned through the election. But we're very pleased with what happened in this rule. It's a great start in moving this process to be a little more equitable, fair, less costly and less burdensome. We'll take it as a win and move on from there.

Physicians Practice: Alrighty, Anders, that's all I got for you. Anything else you want to add?

Gilberg: No, thanks. It's great to see you, Keith.

Physicians Practice: Always a pleasure. Thank you so much.