The Centers for Medicare & Medicaid Services denied recertification to Island Peer Review Organization and Network Medical Review Company as arbiters under the No Surprises Act, citing failure to meet minimum performance standards. Healthcare providers won over 85% of cases in 2025, with IPRO ruling in favor of providers in nearly 97% of disputes. Critics cite financial incentives where arbiters earn $425 to $800 per case, prompting calls from insurers and lawmakers like Rep. Frank Pallone Jr. for complete reform of the arbitration system.
Decertified entities respond to CMS decision
- ▪A spokesperson for Network Medical Review Company defended the firm as high-quality and balanced
- ▪A spokesperson for Island Peer Review Organization expressed disappointment with CMS's decertification of the firm while stating the firm worked to deliver fair decisions
Coalition Against Surprise Medical Billing response
- ▪The Coalition Against Surprise Medical Billing praised the decertification of Island Peer Review Organization and Network Medical Review Company and urged a pause on arbiter recertifications
- ▪The Coalition Against Surprise Medical Billing stated that arbiters have allowed healthcare providers to turn the independent dispute resolution process into a gold rush
Specific provider win rates for decertified arbiters
- ▪Data from price transparency firm Turquoise Health shows Island Peer Review Organization ruled in favor of healthcare providers in nearly 97% of Island Peer Review Organization's cases
- ▪Network Medical Review Company sided with healthcare providers in approximately 70% of its billing dispute arbitrations
Arbitrator compensation and financial incentives
- ▪Independent dispute resolution arbiters earn between $425 and $800 for each medical billing dispute they decide, but receive no payment if a dispute is determined to be ineligible
- ▪A STAT investigation found that independent dispute resolution arbitrators accumulated large profits while frequently deciding in favor of clinicians in billing disputes
- ▪Island Peer Review Organization nearly tripled its revenues during its tenure as an independent dispute resolution arbiter, according to reporting by STAT News
CMS arbiter standards and recertifications
- ▪The Centers for Medicare & Medicaid Services is reviewing recertification applications for eight other independent dispute resolution arbiters
- ▪In a July guidance document, the Centers for Medicare & Medicaid Services listed untimely decisions, inaccurate determinations, and conflicts of interest as possible grounds for arbiter dismissal
High provider win rates and arbitration outcomes
- ▪Healthcare providers are frequently awarded three to four times comparable in-network reimbursement rates when winning independent dispute resolution arbitrations
- ▪Healthcare providers won over 85% of independent dispute resolution cases in 2025, according to federal government data
Systemic challenges and insurer actions
- ▪Insurers and critics allege private equity-backed medical groups pack the independent dispute resolution process with ineligible billing claims to secure higher payouts
- ▪Healthcare providers have submitted substantially more independent dispute resolution claims than federal regulators originally anticipated under the No Surprises Act
- ▪Some health insurers have filed lawsuits or refused to pay arbitration awards following concerns over the independent dispute resolution system
Congressional oversight of arbiters
- ▪Representative Frank Pallone Jr. introduced legislation last month to eliminate the independent dispute resolution arbitration process under the No Surprises Act
- ▪Representative Frank Pallone Jr. sent oversight letters to independent dispute resolution arbiters requesting information on how they reach billing decisions
Story comments
Loading comments…