CMS and the insurance companies are lying to you…. Let me simplify this…. It’s the insurance companies own actions that are driving up costs. The No Surprises Act protects patients from unexpected out-of-network bills for emergency care and certain services at in-network facilities. Patients generally pay only their in-network cost sharing. Payment disputes remain between physicians and insurers. Physicians may be out of network because insurers offer inadequate rates or refuse to include them in their networks. Without a contract, there is no agreed payment rate. If negotiations fail after 30 business days, either side can use independent dispute resolution, or IDR. An arbitrator selects one party’s payment offer for care already provided. Initial payments can be zero, and physician organizations report that insurers sometimes submit offers of $1 or less. Their September 2026 analysis found that insurers defaulted on 24.5% of disputed service lines in 2025 and offered $1 or less on another 8.2%. When insurers refuse to negotiate reasonable rates, practices are forced into arbitration. Providers won approximately 85% of federal IDR determinations in the second half of 2025, including default decisions. Even winning does not guarantee payment. An emergency medicine association survey covering roughly 660,000 IDR claims won in 2025 found that 48% were not paid within the required 30 days. IDR is supposed to discourage insurers from refusing to negotiate and encourage reasonable agreements before arbitration. When insurers fail to participate or pay awards on time, practices incur additional collection costs. Removing those consequences would give insurers less incentive to negotiate and could create more disputes and opportunities for abuse by both sides. Insurers blame IDR costs for rising premiums. But people who pay for out-of-network benefits are already paying for that coverage, and NSA protections also apply to plans without routine out-of-network benefits. Insurers’ refusal to negotiate, failure to participate, and failure to pay awards can create avoidable disputes and administrative costs. Those costs should not be blamed on IDR without acknowledging the insurer conduct that drives them.