UnitedHealth targets No Surprises Act arbitration wins as Congress weighs ending IDR

UnitedHealth Group told Wall Street on Oct. 13 that No Surprises Act arbitration awards are the biggest cost problem in its employer business and accused a small number of clinician groups of abusing the dispute process. Practices that depend on those wins should expect the country's largest payer to fight harder to shrink them.

Physician groups have heard the argument before. "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," Anders Gilberg, senior vice president of government affairs at the Medical Group Management Association (MGMA), told Physicians Practice in a June interview. Gilberg acknowledged a few outrageous cases and some profit-driven ownership arrangements but called them "the exception to the rule."

On the company's third-quarter earnings call, executives said arbitration awards can approach nearly 6 percent of total medical spend in some regions, with some awards running 10 to 11 times what Medicare would pay, according to the call transcript. They said UnitedHealth will keep working with policymakers and regulators to make sure the law works as Congress intended.

The warning came in a strong quarter. UnitedHealth reported $4.1 billion in profit, up from $2.3 billion a year earlier, and a medical loss ratio of 88.4 percent, down from 89.9 percent, as Fierce Healthcare reported. But spending in employer-sponsored plans ran high for a second straight quarter, and executives pointed to arbitration payouts, pricier specialty drugs and providers billing more aggressively, according to Healthcare Dive. They put commercial cost trend above 11 percent and pointed to rising cost intensity from clinicians.

Why the timing matters

UnitedHealth is making its case while Congress debates whether arbitration should exist at all. Rep. Frank Pallone Jr. (D-N.J.), ranking member of the House Energy and Commerce Committee, introduced the Lower Premiums, Faster Payments Act on Oct. 8. According to Holland & Knight's analysis of the bill, it would end open negotiation and IDR for services furnished on or after Jan. 1, 2028, make the qualifying payment amount (QPA) the out-of-network rate, require payment within 30 days and bar judicial review of how the QPA is calculated.

The same analysis notes the bill's near-term prospects look limited with Pallone in the minority. Still, the largest payer publicly tying arbitration to employer premiums hands lawmakers and regulators a ready talking point.

For now, the numbers favor providers. They won 88 percent of resolved disputes in the first quarter of 2024 and 83 percent in the second, and the median winning provider offer ran 383 percent to 447 percent of the QPA, according to Georgetown University's Center on Health Insurance Reforms. Five organizations accounted for 63 percent of resolved cases, the kind of concentration UnitedHealth is pointing to.

Volume keeps climbing. Parties started more than 2.1 million disputes from Jan. 1 through July 31, 2026, according to CMS' latest IDR report. Of the 671,465 disputes closed in June and July, 98,398, or nearly 15 percent, were found ineligible.

What it means for practices

For an independent group that relies on arbitration, the cost intensity complaint is the part to watch. When a payer names clinician billing as a driver of employer costs, practices can expect closer scrutiny of coding levels, more downcoding and more records requests on out-of-network claims.

The best defense is a clean file on every dispute. CMS' tips for disputing parties list what certified IDR entities look for: the complete remittance or denial notice with its codes, a full explanation of benefits, the claim number and the QPA. Practices should also keep the emails or portal records showing they started the 30-business-day open negotiation period, because they must produce them if the payer says negotiation never happened. CMS flags incorrect batching as one of the most common mistakes.

The IDR operations final rule CMS issued in May raises the bar further. Open negotiation notices now go through the federal portal, each party pays a $15 administrative fee per dispute, batched disputes are capped at 50 line items and parties get five business days to answer an IDR entity's request for more information.

Winning is only half the job. Gilberg said in June that providers prevail more than 80 percent of the time "only to receive no payment," and called for "more accountability so that when a provider prevails in the IDR process, they actually get paid in a timely manner." The courts have not filled that gap. On Sept. 17, the 2nd U.S. Circuit Court of Appeals ruled that a provider could not sue Cigna to collect more than $3 million in unpaid awards and pointed it to federal agencies and states for enforcement, Becker's Payer Issues reported.

Physicians Practice laid out nine steps to collect after you win No Surprises Act arbitration earlier this month.

UnitedHealth did not say what it will ask regulators for. Pallone's bill would not take effect before 2028 even if it passed, so arbitration remains the path for today's disputes, and practices that document every step will be in the strongest position however the policy fight ends.