On November 4, 2026, the Departments of Health and Human Services, Labor, and the Treasury (Departments) announced that they are denying recertification to two certified independent dispute resolution entities (IDR entities or IDREs) in the No Surprises Act (NSA) federal IDR process: Island Peer Review Organization, Inc. (IPRO) and Network Medical Review Company, LLC (NMRC). The Departments determined that both entities failed to meet the minimum performance standards required of certified IDR entities. For self-insured employer group health plans, which ultimately pay the IDR awards made against them, this is the first concrete sign that federal regulators are willing to remove arbitrators from a system that has produced lopsided outcomes and rapidly growing plan costs.
Background
The NSA, effective in 2022, established a federal IDR process to resolve certain payment disputes between out-of-network providers and health plans. When open negotiation fails, each party submits an offer to a certified IDR entity, which must select one of the offers as the final payment determination. The initiating party, usually the provider, proposes the IDR entity that will arbitrate the dispute. Although the non-initiating party may propose an alternative IDR entity, payers often receive so many IDR initiations that they struggle to meet the strict deadlines for doing so.
Certified IDR entities must issue timely and impartial payment determinations and must continue to meet certification standards, including timeliness, accuracy, independence, and impartiality, to remain certified. Certifications must be renewed every five years.
As we discussed in previous blog posts here and here, the system was expected to be used relatively infrequently but has instead become a direct and growing cost driver for self-insured plans, which were the named non-initiating party in roughly 68% of disputes in the second half of 2025.
Which IDR Entities Were Denied Recertification, and Why
The Departments’ notice does not detail the specific deficiencies. It states only that IPRO and NMRC did not meet minimum performance standards. Neither entity may accept new disputes, and parties with open disputes before either entity should expect further guidance from the Departments. The decisions are not yet final. Each entity has 30 business days from the date of its written denial notice to appeal, and the Departments will not issue a final denial until the appeal period has elapsed and any appeals have been considered. Eight other entities have completed their public petition periods, and their applications are under review.
Publicly available data and reporting shed light on why these two entities drew scrutiny, although the concerns differ:
- IPRO: the most provider-favorable arbitrator in the system. An analysis of CMS public use file data found that IPRO decided 204,611 disputes in 2025 and found for the provider 98.4% of the time, the highest rate of any entity. Georgetown University researchers noted that in the fourth quarter of 2025 IPRO ruled for providers in 99.4% of disputes with a median award of 601% of the qualifying payment amount (QPA). Because the QPA generally reflects the median contracted in-network rate for a service, IPRO’s median award was roughly six times what an in-network provider would typically receive. By contrast, Medical Evaluators of Texas sided with providers 54.5% of the time with a median award of 159% of QPA.
- NMRC: independence and timeliness concerns. NMRC was not a win-rate outlier. It sided with providers 69.7% of the time in 2025, below the national rate. However, insurers have stated that NMRC’s parent company shares private equity investment with an anesthesia chain that can profit from favorable rulings. NMRC was also among the slower entities, with a 52-business-day median against a 30-business-day statutory clock.
The denials follow increased pressure from employers and payers, who have urged the Departments to scrutinize IDR entities more rigorously at recertification, pointing to disparities in win rates and awards, ineligible determinations, and financial ties to high-volume filers. In September 2026, CMS also announced a new audit program to assess IDR entities’ compliance with the NSA.
Why Outlier Arbitrators Matter to Plan Costs
The disparity among IDR entities is not academic. Arbitrators applying the same statutory factors reach very different results. Moreover, the entities with the highest provider win rates and awards also generally handle the largest volume of cases, likely because providers make the initial choice of entity. Because IDR entities are paid per eligible dispute, critics argue that entities have an incentive to find disputes eligible and rule for providers in order to attract more volume.
The financial effect is significant. Researchers from Georgetown University’s Center on Health Insurance Reforms have estimated that the IDR system cost $22.4 billion from 2022 through 2025, including $15.6 billion in awards above in-network rates. UnitedHealthcare has reported that NSA arbitration awards approach 6% of total commercial medical spend in some regions, and that prevailing out-of-network awards average 11 times Medicare rates. For self-insured plans, these costs land directly on the plan sponsor.
What This Means for Employer Group Health Plans Going Forward
Potential downward pressure on awards. IPRO alone decided more than 200,000 disputes in 2025. If those disputes are redistributed to entities with more balanced records, plans could see fewer losses and smaller awards. However, it is too early to quantify any savings. Most remaining entities still find for providers more than 80% of the time, and providers may simply shift to the next most favorable arbitrator.
Short-term caseload disruption. Removing two entities reduces capacity at a time when dispute volume continues to climb, with 1.75 million disputes in the first half of 2026 alone. Open disputes pending before IPRO and NMRC may be delayed while the Departments issue guidance on next steps, which may affect claims and stop-loss forecasting.
More decisions to come. Eight additional recertification applications are pending, including several entities whose provider win rates exceed 90%. The Departments have stated that they will continue to deny recertification or revoke certification when an entity fails to meet program standards.
Fiduciary oversight remains essential. Surprise billing is a DOL national enforcement priority, and self-insured plans must actively monitor how their TPAs handle out-of-network claims and IDR payments. The Second and Fifth Circuits, along with a number of district courts, have determined that providers have no private right of action to enforce IDR payment awards in court. Even so, these awards remain binding, and the DOL, Treasury, and HHS can still take action against plans that fail to pay. Any decision to withhold payment of an award, including one issued by IPRO or NMRC, should be made in close consultation with counsel.
Thompson Hine Takeaways
Ask your TPA about affected disputes. Request a list of your plan’s open and recently decided disputes before IPRO and NMRC, including amounts claimed and awarded, and how the TPA plans to handle the Departments’ forthcoming guidance.
Monitor IDR entity selection. Confirm that your TPA is actively involved in the IDR entity selection process and proposes alternative IDR entities in disputes when appropriate. Ask your TPA whether it routinely objects to high-outlier entities and whether it screens for conflicts of interest. Either party may reject an entity that has a conflict with one of the parties.
Document fiduciary oversight. Recent litigation against plan sponsors has alleged that poor oversight of plan vendors and costs led to higher premiums, contributions, and out-of-pocket costs. Although those cases have centered on prescription drug pricing and PBM arrangements, the same theory could apply to IDR. Plan sponsors should keep records showing how they monitor TPA handling of IDR disputes and award payments.
Watch the remaining recertification decisions. Decisions on the eight pending applications, and the outcome of any appeals by IPRO and NMRC, will shape the IDR landscape in 2027.
Do not budget for immediate relief. Continue building IDR outcomes into claims and stop-loss forecasting until the data shows that awards are actually declining.
Please contact the author or your Thompson Hine attorney with any questions.
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