Elevance: No Surprises Act IDR awards hit 'extreme' levels for OR

What the research says about the NSA, healthcare costs

The analysis examined over 7,300 payment disputes involving procedures and services that are typically scheduled in advance, such as spine surgery, plastic surgery and colonoscopy, from Elevance Health-affiliated plans. The procedures qualified for the federal IDR process because they were performed at in-network facilities by out-of-network providers.

Researchers found that providers won nearly 90% of claim lines for the disputes analyzed. What's more, the awards were often tens to hundreds of times higher than typical in-network commercial rates and Medicare payment rates, they reported.

For example, the mean award in the analysis was close to $40,000, while the in-network claim amount was about $1,614, and the Medicare price was $645. The mean award was also significantly higher than the contracted price, which was about $766.

Notably, the mean award blew past the qualifying payment amount of roughly $800 identified in the analysis. The QPA is a health plan's median in-network contracted rate for the same service in the same geographic area, using 2019 rates and adjusted for inflation. It is one of the factors arbitrators consider when determining an award under the IDR process.

Providers have criticized the QPA's accuracy in the process, arguing that payers' values are artificially deflated because they use "ghost rates" from providers who rarely or never submit claims for those procedures and have lower rates.

Researchers said ghost rates may be at least partially contributing to the lower QPA values observed in the analysis, considering ratios of IDR awards to in-network claims were extremely high. However, these ratios were still somewhat lower than the awards-to-QPA ratios, indicating that the median claim amount exceeds the QPA, creating a notable gap between these two benchmarks.

Still, the analysis found that most of its payment disputes for the planned procedures were at least 20-100 times the QPA for that service.

Prior research has also found that IDR awards, mostly for emergency care, are, on average, several times higher than the QPA. Elevance says that this is not only the case for planned procedures but also that the "awards are extreme" in these instances.

While surgical procedures and associated neuromonitoring represent only about 16% of disputed line claims, they account for approximately 60% of Elevance's total NSA award costs.

These awards are adding "tens of thousands of, or in some cases even more than one hundred thousand, dollars in excess costs" per claim, researchers said.

Closing the loophole

Elevance said in the analysis that the IDR process appears to have become a strategy for obtaining lucrative reimbursement from insurers while keeping patient out-of-pocket costs low, rather than a last stop for dispute resolution."

Since the IDR process does not return awards close to the in-network rate as anticipated by lawmakers, providers have an incentive to skip patient waiver and consent, according to the analysis.

A May 2026 final rule from CMS should help address this statutory loophole by requiring providers and facilities to attest that disputed services do not qualify for the notice-and-consent exception before entering the IDR process.

But Elevance wants Congress to clarify that the IDR is not for services for which waiver and consent could have been obtained, including emergency services and unforeseen ancillary services delivered during a scheduled service.

The payer also recommended amending the law itself or updating its regulations to reinforce the use of market-based payment benchmarks for awards, such as Transparency in Coverage data, require written rationales for award determinations and provider training on modifier-based reimbursement standards, especially since assistant surgeons filed the most disputes in the analysis.

However, some providers have contended that Elevance has taken the matter into its own hands -- an attempt that they say also tries to bypass the rules of the NSA.

Elevance's subsidiary, Anthem, has implemented a new out-of-network policy in about a dozen states that penalizes in-network facilities with nonparticipating providers who render services to members of its self-funded plans.

Noncompliant facilities face an administrative penalty of up to 10% of the allowed amount of the facility's claim that involves the participating provider. Further noncompliance could result in termination from Anthem's networks.

Hospitals and health associations, including the American Hospital Association and the California Hospital Association, sued and aggressively fought Anthem because they felt the policy unfairly penalized facilities for staffing matters completely out of their control.

They also said the policy deliberately circumvents the NSA by imposing blanket fines rather than using the legally mandated IDR process.

Elevance has defended the policy as a means to protect patients and employers from rising healthcare costs and providers undermining the NSA.

Jacqueline LaPointe is an Executive Editor at Xtelligent Healthcare Media, covering revenue cycle management, healthcare payers, health policy and health IT since 2016.