Feds clear up IDR backlog as providers plead for more progress

Modern Healthcare – Tuesday, October 7, 2025
By Bridget Early

Federal regulators say they have made inroads into speeding up the process to resolve out-of-network billing disputes. It’s not enough for frustrated providers and health insurance companies.

The No Surprises Act’s Independent Dispute Resolution, or IDR, process has been a punching bag for both camps since it launched in 2022, and a backlog of cases had piled up by the beginning of this year.

But the share of IDR cases unsettled after 30 business days fell from 69% in January to 34% in July, the most recent month for which data are available, according to the Health and Human Services, Labor and Treasury departments. Likewise, 96.5% of disputes submitted since 2022 are either resolved or are less than 30 business days old, the departments wrote in a notice published Sept. 19.

“The departments’ efforts have delivered remarkable improvements in the throughput of cases compared to prior years,” the notice says. “IDR entities are now resolving disputes faster than they are submitted.”

Providers can see the the difference and HHS Secretary Robert F. Kennedy Jr. is receptive to physicians’ concerns, but more progress is needed and the backlog must be eliminated, said Dr. Anthony Cirillo, president of the American College of Emergency Physicians.

“It’s better, but still not meeting the mission,” Cirillo said. “From a financial, cashflow point of view, yes, it’s nice to see that between January and July, they’re down to 34% are older than 30 business days. They’re supposed to be at zero.”

The outstanding problems are particularly acute for smaller providers, who are still experiencing delayed payments, said Dr. Lisa Maurer, who practices for Wauwatosa, Wisconsin-based Emergency Medicine Specialists.

Emergency Medicine Specialists had to wait about five months for a final determination of claims it submitted under IDR in May, Maurer said. This creates real cashflow problems, said Maurer, who is also chief medical officer at the Wauwatosa-based revenue cycle management company ConsensioHealth.

“Any small company would struggle with that kind of business model,” Maurer said.

Under the No Surprise Act, out-of-network providers and insurers take billing disagreements to third-party mediators known as IDR entities. While intended to cut down on unexpected medical bills and provide a mechanism for insurers and providers to work out deals on reimbursement, the parties have complained from the start that it is too complex and is overburdened.

The number of IDR cases each year has been 100 times greater than expected, HHS, Labor and Treasury wrote in the notice. In addition, insurers and providers collectively spent more than $5 billion on IDRs from 2022 through 2024, according to the Georgetown University Center on Health Insurance Reforms.

To mitigate these shortcomings, HHS, Labor and Treasury implemented several changes.

The regulators introduced an automated system to determine whether disputes qualify for No Surprise Act arbitration, issued additional regulatory guidance, paused new cases to prioritize older ones, and provided assistance and information to providers, insurers and IDR entities, they wrote in the notice.

The Centers for Medicare and Medicaid Services also aims to build up the number of IDR entities and is reviewing 120 applications, according to HHS, Labor and Treasury. There are 15 IDR entities since CMS added two in July.

Federal authorities and the participants have gotten better at managing the IDR process with practice, said Jack Hoadley, a research professor emeritus from the Georgetown University Health Policy Institute.

“They’re right to brag that during the most recent two-month period that they reported on, they actually settled more cases than then came in fresh,” Hoadley said. “That says the backlog pile is, in fact, going down.”

Providers and insurers would like to see more, starting with the publication of a long-awaited final rule. Regulators issued the proposed rule in 2023. According to the White House’s regulatory agenda for this year, that rule is slated to come out next month.

Clearer information about how federal authorities determine whether cases are eligible for IDR would be a help, a spokesperson for the health insurance industry trade group AHIP said.

The government also could clarify when providers are permitted to submit batches of claims in a single complaint and determine whether to retain the 90-day “cooling off” period during which providers can’t request arbitration for the same type of services under review in other cases, said Jeffrey Davis, health policy director at the consulting firm McDermott+.

“Everyone’s kind of confused about what, exactly, fits in a cooling-off period, which is creating the effect of things just getting stuck in this perpetual 90-day cooling-off period,” Davis said.

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