Matt dives into a specific healthcare topic to help those in the industry, and those outside of it, better understand the market drivers causing today’s healthcare challenges.

Federal regulators expected roughly 17,000 surprise-billing arbitration disputes a year. Providers filed about 2.5 million in 2025, followed by another 1.4 million in the first five months of 2026. That gap is not a rounding error. It raises a more important question for patient advocates: when insurers and providers enter arbitration over payment, who is in the room representing the patient?

The No Surprises Act accomplished something important. Research cited by congressional investigators credits the law with preventing nearly 20 million surprise medical bills in 2024. Patients were no longer supposed to be trapped between an out-of-network provider and a health plan over charges they could not reasonably anticipate.

But the law also created an independent dispute resolution process for payment disagreements between providers and insurers. That backstop was intended to resolve disputes when negotiation failed. Instead, it has become a high-volume system. Congressional oversight materials say a small number of provider organizations, many backed by private equity, account for a large share of filings.

The financial consequences are now part of the policy debate. Georgetown University researchers estimate that the IDR process generated $22.4 billion in costs from 2022 through 2025, including payment awards above in-network benchmarks, internal administrative costs, and arbitration fees. Provider groups and insurers disagree over how the system should be measured and reformed, but the scale of the process is no longer difficult to see.

The structure of the arbitration process deserves scrutiny because incentives shape behavior. Independent dispute resolution entities are paid to process disputes, while cases found ineligible do not generate the same entity fee. Critics argue that this can create pressure to accept more cases. Providers, meanwhile, have a strong reason to keep filing when awards substantially exceed common payment benchmarks.

Recent reporting has highlighted extreme examples. One dispute involved an award of about $440,000 for a breast reduction procedure that was described as typically costing around $20,000. Examples like this do not describe every arbitration case, but they help explain why lawmakers are asking whether the system is operating as Congress intended.

Rep. Frank Pallone, the ranking Democrat on the House Energy and Commerce Committee, sent oversight letters to six certified dispute-resolution firms in September: C2C Innovative Solutions, Commence, Dane Street, EdiPhy Advisors, National Medical Reviews, and ProPeer Resources. His requests cover eligibility decisions, compensation structures, quality controls, use of automated tools, high-volume filers, and potential financial relationships. Responses were requested by September 24, 2026.

The central patient issue is no longer the surprise bill at the bedside. It is what happens when the cost of resolving payment disputes moves through the broader healthcare system. Pallone has said he is concerned that the IDR process is contributing to higher out-of-pocket costs and premiums for consumers.

That is the part advocacy leaders should watch closely. A law can protect a patient from one direct bill while still creating downstream cost pressure elsewhere. If arbitration awards, administrative fees, or contracting behavior increase system spending, patients can encounter the consequences through premiums, cost sharing, or access decisions even though they never participated in the original dispute.

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Patient groups fought for protections from surprise medical bills because the old system put patients in the middle of disputes they could not control. Implementation deserves the same attention as passage. When advocates leave the details entirely to insurers, providers, arbitrators, and regulators, the patient perspective can disappear from the part of policymaking where incentives are actually set.

That does not mean patient organizations need to choose a side in every provider-insurer payment dispute. It means they can ask a different set of questions:

Advocacy leaders can stay involved after a bill becomes law by tracking implementation, commenting on proposed rules, collecting patient cost and access data, and bringing that evidence back to regulators and congressional staff. Industry partners can support that work by treating advocacy relationships as early-warning systems for emerging affordability and access problems rather than as one-time engagement exercises.

The No Surprises Act shows why patient advocacy cannot end at the signing ceremony. Protecting patients requires attention to what a law does in practice, who benefits from its incentives, who absorbs its costs, and whether the people the law was designed to protect still have a voice when the system evolves.

For advocacy leaders, the immediate question is simple: what have your members experienced with premiums, out-of-pocket costs, and access since the law took effect? Put that evidence into the policy conversation. For industry leaders, understand how the advocacy community experiences your engagement before the next ELAVAY cycle opens.

Take the Advocacy Influence Diagnostic. It takes five minutes, is free and anonymous, and returns an Advocacy Visibility Index and a Strategic Risk Score, showing whether your advocacy function sits close enough to the decision to matter in a fight like this one. The 2025/2026 ELAVAY Report is available now, and fielding for 2026/2027 opens in October. Reach me directly at [email protected].