Two arbitrators benched
Federal regulators have barred two of the 17 surprise-billing arbitrators from new disputes, citing their performance. Which standards they missed, and what becomes of their open cases, the agencies have not yet said.
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read by an AI voiceOn Nov. 4 three federal departments denied recertification to two of the private organizations that settle surprise-billing disputes between insurers and the doctors and hospitals outside their networks. Health and Human Services, Labor and the Treasury said that Island Peer Review Organization, a nonprofit that does business as IPRO, and Network Medical Review Company had "failed to meet minimum performance standards." Neither firm may now accept a new dispute. A study published in September found that, in cases filed in 2023, one of them had sided with providers more often than most arbitrators, and the other less often.
The firms are arbitrators under the No Surprises Act. The law banned balance billing, the practice of charging patients the gap between an out-of-network price and what their insurer paid, in the situations it covers, which are emergency care, air ambulance flights and care from an out-of-network clinician during a visit to an in-network hospital or other facility. It also set up arbitration to settle that gap between insurer and provider. When the two sides cannot agree on their own, each submits an offer and a certified entity chooses one, after weighing factors set out in the law. The side whose offer is not chosen generally pays the arbitrator's fee. Certification lasts five years, and this autumn the agencies have been reviewing the firms that applied to renew.
The work has grown quickly. Parties filed more than 2.5 million disputes in 2025, according to the Centers for Medicare and Medicaid Services, or CMS, and in the second half of that year the provider's side, whether a clinician, a hospital or an air ambulance service, won about 85% of the payment decisions. In the first nine months of this year nearly 2.9 million were filed, already more than in all of 2025. That is more than 10,000 a day.
Until recently the government's public files did not say which arbitrator had decided each case. CMS began naming the firm behind each decision only with its data for the second half of 2025. The September study, by Philip Valtadoros of the economics department at the University of Texas at Austin, drew instead on records of cases filed in 2023 that he obtained under the Freedom of Information Act. Taking each disputed service separately, IPRO chose the provider's offer 89% of the time, against 81% overall. Network Medical Review Company chose it 74% of the time.
The study describes these differences without explaining them. Its author writes that they are not causal estimates, because disputing parties can choose an arbitrator for each dispute and each arbitrator's mix of cases may differ. The agencies' notice says that certified firms must keep meeting requirements related to timeliness, accuracy, and independence and impartiality in making payment decisions, without saying which of them the two firms missed. Guidance the agencies issued in July says a renewal review may weigh, among other things, whether a firm decides large numbers of disputes on time, rules accurately on eligibility and payment, explains its payment decisions as the rules require and handles fees properly. Applicants are also checked for conflicts of interest.
On Oct. 1 Mehmet Oz, the administrator of CMS, and Daniel Aronowitz, an assistant secretary of labor, met representatives of every certified firm. Users of the process had complained of ineligible disputes, unclear reasons for decisions, and awards paid late or not at all. Later in October CMS opened public petition periods, in which anyone could object to a firm's renewal, for five firms and then three more, among them Maximus Federal Services and Acentra. The agencies say that the other firms that applied to renew are still under review now that those periods have closed, and that they will announce their status later.
Insurers and employers had asked for more. In letters to top administration officials in October, the Coalition Against Surprise Medical Billing, a payer advocacy group, and the ERISA Industry Committee, which represents large employers, urged CMS to stop approving arbitrators until it adopted more rigorous standards. The coalition also wanted the five-day window for objections stretched to at least 30 days. The American Society of Anesthesiologists and other physician groups, for their part, have opposed a House bill from Representative Frank Pallone Jr. of New Jersey, who helped write the law. Under it, physicians who treat patients out of network at in-network facilities would lose federal arbitration for services provided from 2028. Patrick Giam, the society's president, said that giving insurers even greater control over physician payments was not the solution to concerns about the process.
Network Medical Review has said that it plans to appeal, and IPRO that it is considering next steps that may include an appeal. Much else is still open. The two firms have 30 business days from their written notice to appeal, and the agencies will not issue a final denial until that time has run out and any appeal has been considered. Parties with cases before either firm have been told to expect further guidance on next steps. The July guidance says that a firm denied recertification that appeals may keep working on disputes already assigned to it until its five-year term ends, though it may take no new ones. When the term ends, its unfinished disputes go to other certified firms and its fees for them are refunded. The notice does not say how that will apply here, how many cases the two firms hold or when their certifications end.
For now the government's list of certified arbitrators still shows 17 names. Two of them, IPRO and Network Medical Review Company, carry a note saying that the firm is not accepting new disputes at this time.
- The Nov. 4 decisionIn a notice dated Nov. 4, 2026, the Departments of Health and Human Services, Labor and the Treasury said they are denying recertification of Island Peer Review Organization, Inc. (d.b.a. IPRO) and Network Medical Review Company, LLC, which they determined failed to meet minimum performance standards required under 26 CFR 54.9816-8(e), 29 CFR 2590.716-8(e) and 45 CFR 149.510(e). To remain certified, the notice says, IDR entities must continue to meet the standards for certification set out in the NSA and regulations, including requirements related to timeliness, accuracy, and independence and impartiality in making payment determinations. Neither is eligible to accept new disputes; parties with open disputes before them are to expect further guidance. Each may request an appeal within 30 business days of the written denial notice, and no notice of final denial will issue until the appeal period has elapsed and any appeals received have been considered. The eight other entities named in the October petition periods have completed them; the Departments are reviewing the petitions, and the remaining applicants are still under review. The notice does not name the specific standards the two entities missed, their expiration dates or their open caseloads, and as of Nov. 13, 2026 no later notice had been posted. Network Medical Review said in an email that it plans to appeal, and IPRO that it is considering next steps, which may include appealing the decision (STAT, republished by The Boston Globe, Nov. 5, 2026); IPRO also said it was disappointed with the decision (Healthcare Dive, Nov. 6, 2026). The Coalition Against Surprise Medical Billing said the Departments' actions reinforce the clear need for greater accountability, transparency and oversight of IDR entities.
- The list of certified entitiesCMS's list of certified IDR entities (page last modified 11/10/2026 10:15 AM) shows 17 entities. Island Peer Review Organization (DBA: IPRO), application IDREApp-066, and Network Medical Review Company (DBA: Network Medical Review Company, Ltd.), application IDREApp-071, each carry the note Not accepting new disputes at this time, in parentheses; the page gives no reason or date for the notes. Physio Solutions, LLC (DBA: medlitix), whose certification the Departments announced on Sept. 11, 2026, expanding the number of certified entities from 16 to 17, carried the same note on Nov. 5 but no longer does; Healthcare Dive (Sept. 15, 2026) reported that, although officially certified, it was not then accepting new disputes, and AHA News (Nov. 10, 2026) reported that it is now available to adjudicate disputes. Fees listed for 2026: IPRO $740 for a single determination, $1,075 batched and $250 tiered; Network Medical Review Company $450, $750 and $90. IPRO's IDR page describes it as a nonprofit and as one of the first certified IDR entities. As of Nov. 13, 2026, neither IPRO's IDR page nor Network Medical Review's Federal IDR Process page carried a statement on the decision.
- How federal arbitration worksCongressional Research Service report R48738 (Nov. 26, 2025): if an insurer and an out-of-network provider cannot reach agreement during open negotiation, either may start independent dispute resolution. In this baseball-style arbitration each submits a payment amount, and the certified IDR entity selects between the parties' offers after considering a list of statutory factors. Both parties pay an administrative fee to the government, and, generally, the party whose offer is not chosen pays the IDR entity's fee. Valtadoros (Health Affairs Scholar, 2026) describes the No Surprises Act as having banned balance billing and established IDR for insurers and out-of-network providers to resolve payment disputes over out-of-network services.
- Recertification rulesThe Departments' recertification FAQs (July 2026): certification, including recertification, is effective for a 5-year period. In reviewing an application the Departments may consider an entity's ability to make timely determinations on a high volume of dispute assignments; complete eligibility and payment determinations accurately in accordance with statutory and regulatory timelines; provide rationales for payment determinations meeting regulatory requirements; and collect and process fees as appropriate. Applicants are reviewed for potential conflicts of interest and undergo a public petition period if they meet the minimum qualification standards. A denied entity may request a hearing within 30 business days; if it has submitted an appeal, it may continue to work on in-progress disputes up until the end of its 5-year period but may not accept new disputes unless recertified. An entity stops receiving new disputes 90 calendar days before its certification expires; disputes it has not completed by expiration are reassigned to existing certified IDR entities, and it must refund its fees for reassigned disputes.
- Volume and outcomes, 2025 and 2026CMS's Supplemental Background on Federal IDR Public Use Files for July 1 to Dec. 31, 2025: 1,372,563 disputes initiated, 16% more than the first six months of 2025 (1,186,812); 1,449,900 disputes closed; 1,145,039 payment determinations. Providers, facilities or providers of air ambulance services prevailed in approximately 85% of payment determinations, against 88% in the first six months; the prevailing offer was higher than the qualifying payment amount in approximately 87%. The two halves of 2025 sum to 2,559,375 disputes, and the 2026 figure over the 273 days from Jan. 1 to Sept. 30 is more than 10,600 a day (both computed from CMS's figures). CMS's bi-monthly report as of Sept. 30, 2026: 2,895,872 disputes initiated and 2,324,151 payment determinations from Jan. 1 to Sept. 30, 2026. The public use files for 2025 Q3 and Q4 (as of July 22, 2026) are the first in which each dispute line item includes the name of the certified IDR entity.
- Outcomes by arbitrator, 2023 casesValtadoros, Department of Economics, University of Texas at Austin (Health Affairs Scholar, vol. 4, issue 10, published Sept. 28, 2026): a descriptive analysis of CMS public use files and a dataset obtained under the Freedom of Information Act on arbitrator identity and selection method for the 677,137 disputes initiated in 2023, of which 517,734 decided cases matched. Provider win rate, the percentage of line items in which the provider won, ranged across 13 arbitrators from 45% (Keystone) to 93% (EdiPhy Advisors), with an overall mean of 81%. IPRO: win rate 89%, decision rate 68% (initiated cases decided by the selected arbitrator), average payment 529% of the qualifying payment amount, wait time 223 days, 49,324 cases. Network Medical Review Company: 74%, 78%, 411%, 281 days, 55,906 cases. The author writes that the differences are not causal estimates and that each arbitrator's case composition may differ.
- The month before the decisionCMS news alert (Oct. 2, 2026): on Oct. 1, CMS Administrator Dr. Mehmet Oz, Department of Labor Assistant Secretary Daniel Aronowitz and officials of the three Departments met representatives from all certified IDR entities; users had raised concerns about ineligible disputes, unclear determination rationales and delayed payment or nonpayment. American Hospital Association news, Oct. 16, 2026: a petition period through Oct. 23 for Maximus Federal Services, Inc.; ProPeer Resources LLC; C2C Innovative Solutions, Inc.; Medical Evaluators of Texas ASO, LLC; and Federal Hearings and Appeals Services, LLC. Oct. 23, 2026: a petition period through Oct. 29 for National Medical Reviews Inc.; Keystone Peer Review Organization, Inc. (also doing business as Acentra); and MCMC Services LLC.
- Insurers, employers and physician groupsHealthcare Dive (Jill Hughes, Oct. 28, 2026): the Coalition Against Surprise Medical Billing, a payer advocacy group (letter sent Oct. 22), and the ERISA Industry Committee, which represents large employers, wrote to top administration officials asking CMS to stop approving arbiters until it implements more rigorous standards; the coalition asked that the five-day petition window increase to at least 30 days. Medical Economics (Oct. 13, 2026): Rep. Frank Pallone Jr. (D-N.J.), who helped write the No Surprises Act in 2020, announced the Lower Premiums, Faster Payments Act on Oct. 8, under which physicians who treat patients out of network at in-network facilities would lose access to federal arbitration for services furnished on or after Jan. 1, 2028. The American Society of Anesthesiologists, the American College of Emergency Physicians and the American College of Radiology came out against it the day it was announced. Patrick Giam, MD, president of the anesthesiologists' society, said giving insurers even greater control over physician payments is not the solution to concerns about the IDR process.