Why Health Plans Keep Losing on Out-of-Network Claims

Out-of-network claims are quietly draining health plans, and the arbitration process meant to settle them is tilted against payers. According to Healthcare Dive, roughly 88% of disputes that reach the federal Independent Dispute Resolution (IDR) process under the No Surprises Act are decided in favor of providers. When a claim lands in IDR, the plan usually loses and ends up paying more than it expected.

The volume of IDR cases has far exceeded what regulators anticipated when the No Surprises Act took effect, straining a system that was supposed to be a last resort. Every dispute also carries administrative cost and arbitration fees on top of the eventual payout, so escalation is expensive even before the ruling.

The practical takeaway for payers is to solve OON claims earlier. Accurate pricing, faster resolution, and better initial payment determinations keep claims out of arbitration entirely. Plans that treat IDR as the fix are optimizing the wrong end of the process.