IDR, Premiums, and the Evidence Congress Still Needs

Can IDR awards explain higher health insurance premiums?

They may be one cost that employers and plans examine, but an award total does not, on its own, establish a premium increase or its cause. A credible assessment must distinguish filed disputes from eligible disputes, selected awards from amounts actually paid, and unusual outliers from typical cases. It must also account for the initial payment and the conduct of both parties before and during IDR.

Halkovich Law's perspective

Employers should know what their plans spend, and Congress should examine whether the federal process is working as intended. But concentrating only on provider win rates or a handful of striking awards misses the questions most relevant to reform: Were initial payments reasonable? Did the plan submit a meaningful offer? Was the dispute eligible? Was the selected amount actually paid, and when?

These are not excuses for an unsupported provider claim. They are the facts needed to distinguish misuse of a process from use of the process to remedy a low payment. A defensible policy analysis should test both possibilities rather than assuming either one.

Politico also reports disagreement over whether the qualifying payment amount, or QPA, should play a stronger role. That benchmark deserves scrutiny: CMS says an August 2026 Fifth Circuit ruling affirmed portions of a judgment striking certain QPA-calculation regulations and guidance. The ruling does not make every QPA wrong, and the federal IDR process remains operational. It does mean that treating a QPA comparison as an unquestioned measure of excess is unsound.

What a meaningful review would include

• Claim-level initial payments, open-negotiation records, and both parties' final offers—not just the winning offer.
• Eligibility decisions, defaulted cases, and reasons disputes entered IDR in the first place.
• How the applicable QPA was calculated and whether it is a reliable comparator for the service at issue.
• Determination-to-payment timelines, unpaid awards, and the amount ultimately borne by the plan or employer.
• Separate evidence of any premium effect, rather than an assumption that every award dollar passed through to employees.

Patients remain the central protection of the No Surprises Act. Improving dispute administration should preserve that protection while demanding accurate information and good-faith participation from providers and plans alike.

Frequently asked questions

Sources and scope

This article is provider-side commentary on a policy debate, not a finding that IDR has no effect on premiums. Politico's reporting and the ERISA Industry Committee's advocacy paper are distinct from CMS's notice concerning the QPA ruling. Claim-specific disputes and premium effects require their own evidence.