{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,29]],"date-time":"2026-10-29T23:54:38Z","timestamp":1793318078429,"version":"4.5.0"},"reference-count":37,"publisher":"Cambridge University Press (CUP)","license":[{"start":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T00:00:00Z","timestamp":1790726400000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["cambridge.org"],"crossmark-restriction":true},"short-container-title":["HEPL"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>The No Surprises Act (NSA), signed into law by\u00a0President Trump over five years ago, marked a significant federal intervention aimed at shielding millions of consumers with private health coverage from unexpected out-of-network medical bills. While the Act is lauded for successfully protecting consumers, its implementation has been plagued by aggressive litigation, with provider-led lawsuits challenging the Act itself as well as every rule issued to implement the protections and countless other lawsuits challenging actions (or inactions) by providers, insurers, and independent dispute resolution (IDR) entities. This litigation has profoundly impacted the Act\u2019s cost-saving objectives by eroding its payment methodology and fostering extensive use of the IDR process. This paper chronicles the litigation timeline from the passage of the NSA through April 2026 and its impacts on the implementation, detailing the challenges to the regulatory framework and how adversarial legalism shaped the NSA\u2019s trajectory. The paper concludes by offering policy options for Congress, federal agencies, states, and stakeholders to reduce costs and IDR volume to better align with the intent of the NSA.<\/jats:p>","DOI":"10.1017\/s1744133126100723","type":"journal-article","created":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T13:28:57Z","timestamp":1790774937000},"page":"1-20","update-policy":"https:\/\/doi.org\/10.1017\/policypage","source":"Crossref","is-referenced-by-count":1,"title":["Litigating the No Surprises Act: how legal challenges undermined cost containment and reshaped provider payments"],"prefix":"10.1017","author":[{"ORCID":"https:\/\/orcid.org\/0009-0003-0144-0032","authenticated-orcid":false,"given":"Lindsey","family":"Murtagh","sequence":"first","affiliation":[{"id":[{"id":"https:\/\/ror.org\/05gq02987","id-type":"ROR","asserted-by":"publisher"}],"name":"Brown University School of Public Health"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ayesha","family":"Rahim","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/05gq02987","id-type":"ROR","asserted-by":"publisher"}],"name":"Brown University School of Public Health"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Erin","family":"Fuse Brown","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/05gq02987","id-type":"ROR","asserted-by":"publisher"}],"name":"Brown University School of Public Health"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"56","published-online":{"date-parts":[[2026,9,30]]},"reference":[{"key":"S1744133126100723_ref2","unstructured":"Adler, L , Fiedler, M and Agarwal, V (2026) No Surprises Act Arbitration Databook. Brookings. April 20. https:\/\/www.brookings.edu\/articles\/no-surprises-act-arbitration-databook\/."},{"key":"S1744133126100723_ref26","unstructured":"House Committee on Energy & Commerce (2020) Congressional committee leaders announce surprise billing agreement. Available at https:\/\/perma.cc\/362S-96SU."},{"key":"S1744133126100723_ref32","unstructured":"Congressional Research Service (2025) No Surprises Act (NSA) independent dispute resolution (IDR) process data analysis for 2023.\u00a0Available at https:\/\/www.congress.gov\/crs-product\/R48359."},{"key":"S1744133126100723_ref6","unstructured":"Centers for Medicare & Medicaid Services (2022a) Amendment to the calendar year 2023 fee guidance for the Federal Independent Dispute Resolution process under the No Surprises Act: Change in administrative fee. December 23. Available at https:\/\/www.cms.gov\/cciio\/resources\/regulations-and-guidance\/downloads\/amended-cy2023-fee-guidance-federal-independent-dispute-resolution-process-nsa.pdf#:~:text=1%20The%20Departments%20of%20Health%20and%20Human,further%20in%20Section%20II%20of%20this%20guidance."},{"key":"S1744133126100723_ref37","doi-asserted-by":"publisher","DOI":"10.1093\/haschl\/qxaf011"},{"key":"S1744133126100723_ref18","doi-asserted-by":"publisher","DOI":"10.1111\/1468-0009.12464"},{"key":"S1744133126100723_ref31","unstructured":"Pelech, D (2024) CBO\u2019s approach to estimating the budgetary effects of the No Surprises Act of 2021. Available at https:\/\/www.cbo.gov\/system\/files\/2024\u201303\/59878-Pelech.pdf."},{"key":"S1744133126100723_ref11","doi-asserted-by":"publisher","DOI":"10.1377\/hlthaff.2020.00217"},{"key":"S1744133126100723_ref23","doi-asserted-by":"publisher","DOI":"10.1377\/forefront.20250820.13433"},{"key":"S1744133126100723_ref10","unstructured":"Centers for Medicare and Medicaid Services (2023) Chart for determining the applicability for the Federal Independent Dispute Resolution (IDR) process. Available at https:\/\/www.cms.gov\/files\/document\/caa-federal-idr-applicability-chart.pdf."},{"key":"S1744133126100723_ref27","unstructured":"Keith, K (2022) Court sets aside key parts of No Surprises Act rule. Health Affairs Forefront. February 24. https:\/\/www.healthaffairs.org\/do\/10.1377\/forefront.20220224.298748\/full\/."},{"key":"S1744133126100723_ref33","doi-asserted-by":"publisher","DOI":"10.26099\/DVQX-DS52"},{"key":"S1744133126100723_ref21","doi-asserted-by":"publisher","DOI":"10.1377\/forefront.20241118.460467"},{"key":"S1744133126100723_ref20","doi-asserted-by":"publisher","DOI":"10.1017\/S1744133124000239"},{"key":"S1744133126100723_ref30","doi-asserted-by":"publisher","DOI":"10.26099\/w3mh-j302"},{"key":"S1744133126100723_ref29","unstructured":"Keith, K (2026) First two court decisions in insurer lawsuits under the No Surprises Act. O\u2019Neill Institute. April 16. https:\/\/oneill.law.georgetown.edu\/california-court-issues-first-decision-in-insurer-lawsuits-under-the-no-surprises-act\/."},{"key":"S1744133126100723_ref36","unstructured":"U.S. House of Representatives Committee on Ways and Means (2025) Letter to Secretaries Kennedy, Bessent, and Chavez-DeRemer. Available at https:\/\/waysandmeans.house.gov\/wp-content\/uploads\/2025\/09\/WM-NSA-Letter-2025-FINAL.pdf."},{"key":"S1744133126100723_ref12","doi-asserted-by":"publisher","DOI":"10.26300\/MMCE-Z888"},{"key":"S1744133126100723_ref15","unstructured":"Department of Labor, Department of Health and Human Services, and Department of the Treasury (2026) FAQ about Consildated Appropriations Act 2021 implementation part 73. Available at https:\/\/www.cms.gov\/files\/document\/faqs-part-73.pdf."},{"key":"S1744133126100723_ref1","unstructured":"Adler, L (2019) Experience with New York\u2019s Arbitration Process for Surprise out-of-Network Bills.\u00a0Brookings. October 24. https:\/\/www.brookings.edu\/articles\/experience-with-new-yorks-arbitration-process-for-surprise-out-of-network-bills\/."},{"key":"S1744133126100723_ref19","doi-asserted-by":"publisher","DOI":"10.1377\/hlthaff.2016.0970"},{"key":"S1744133126100723_ref3","unstructured":"Adler, L , Fiedler, M and Ippolito, B (2021) Understanding the No Surprises Act. Brookings. February 4. https:\/\/www.brookings.edu\/articles\/understanding-the-no-surprises-act\/."},{"key":"S1744133126100723_ref14","unstructured":"Department of Health and Human Services (2024) Letter to Gov. Hochul et Al. Available at https:\/\/www.cms.gov\/caa-enforcement-letters-new-york.pdf."},{"key":"S1744133126100723_ref16","doi-asserted-by":"publisher","DOI":"10.1177\/002200278002400407"},{"key":"S1744133126100723_ref17","unstructured":"Fiedler, M and Adler, L (2024) A first look at outcomes under the No Surprises Act arbitration process. Brookings. March 27. https:\/\/www.brookings.edu\/articles\/a-first-look-at-outcomes-under-the-no-surprises-act-arbitration-process\/."},{"key":"S1744133126100723_ref28","doi-asserted-by":"publisher","DOI":"10.1377\/forefront.20250825.803087"},{"key":"S1744133126100723_ref9","unstructured":"Centers for Medicare & Medicaid Services (2025) Supplemental background on Federal Independent Dispute Resolution public use files January 1, 2025 \u2013 June 30, 2025. Available at https:\/\/www.cms.gov\/files\/document\/federal-idr-supplemental-background-2025-q1-2025-q2.pdf."},{"key":"S1744133126100723_ref22","doi-asserted-by":"publisher","DOI":"10.1215\/03616878-9417470"},{"key":"S1744133126100723_ref35","unstructured":"U.S. House of Representatives Committee on Ways and Means (2023) Letter to Secretaries Beccera, Yellen, and Su. Available at https:\/\/waysandmeans.house.gov\/wp-content\/uploads\/2023\/11\/23.11.9-Smith-Ways-and-Means-NSA-Letter.pdf."},{"key":"S1744133126100723_ref13","unstructured":"Congressional Budget Office (2021) Estimate for divisions O through FF, H.R. 133, Consolidated Appropriations Act. Available at https:\/\/perma.cc\/W4VG-PLJ3."},{"key":"S1744133126100723_ref25","unstructured":"Hoadley, J , Watts, K , Keith, K and DeGarmo, E (2026) The No Surprises Act IDR process: An early look at 2025 data. Health Affairs Forefront. March 20. https:\/\/www.healthaffairs.org\/do\/10.1377\/forefront.20260318.548269\/full\/."},{"key":"S1744133126100723_ref34","doi-asserted-by":"publisher","DOI":"10.1001\/jamainternmed.2019.3451"},{"key":"S1744133126100723_ref8","unstructured":"Centers for Medicare & Medicaid Services (2023) Supplemental background on Federal Independent Dispute resolution public use files January 1, 2023 \u2013 June 30, 2023. February 15. Available at https:\/\/www.cms.gov\/files\/document\/federal-idr-supplemental-background-2023-q1-2023-q2.pdf."},{"key":"S1744133126100723_ref24","doi-asserted-by":"publisher","DOI":"10.1377\/forefront.20250609.318536"},{"key":"S1744133126100723_ref5","unstructured":"AHIP (2024) No Surprises Act continues to prevent more than 1 million surprise bills per month, while provider networks grow. January 26. Available at https:\/\/www.ahip.org\/resources\/no-surprises-act-continues-to-prevent-more-than-1-million-surprise-bills-per-month-while-provider-networks-grow."},{"key":"S1744133126100723_ref7","unstructured":"Centers for Medicare & Medicaid Services (2022b) Calendar year 2023 fee guidance for the Federal Independent Dispute Resolution process under the No Surprises Act. October 31. Available at https:\/\/www.cms.gov\/cciio\/resources\/regulations-and-guidance\/downloads\/cy2023-fee-guidance-federal-independent-dispute-resolution-process-nsa.pdf."},{"key":"S1744133126100723_ref4","unstructured":"Adler, L and Trish, E (2021) Who are the winners in the No Surprises Act? USC Schaeffer, December 4. https:\/\/schaeffer.usc.edu\/research\/who-are-the-winners-in-the-no-surprises-act\/."}],"container-title":["Health Economics, Policy and Law"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.cambridge.org\/core\/services\/aop-cambridge-core\/content\/view\/S1744133126100723","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T13:29:03Z","timestamp":1790774943000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.cambridge.org\/core\/product\/identifier\/S1744133126100723\/type\/journal_article"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,30]]},"references-count":37,"alternative-id":["S1744133126100723"],"URL":"https:\/\/doi.org\/10.1017\/s1744133126100723","relation":{},"ISSN":["1744-1331","1744-134X"],"issn-type":[{"value":"1744-1331","type":"print"},{"value":"1744-134X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,30]]},"assertion":[{"value":"\u00a9 The Author(s), 2026. Published by Cambridge University Press","name":"copyright","label":"Copyright","group":{"name":"copyright_and_licensing","label":"Copyright and Licensing"}},{"value":"This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (https:\/\/creativecommons.org\/licenses\/by\/4.0\/), which permits unrestricted re-use, distribution and reproduction, provided the original article is properly cited.","name":"license","label":"License","group":{"name":"copyright_and_licensing","label":"Copyright and Licensing"}},{"value":"This content has been made available to all.","name":"free","label":"Free to read"}]}}