In the ever-evolving landscape of healthcare regulations, the No Surprises Act (NSA) continues to shape how providers and payers interact, particularly in emergency and out-of-network scenarios. As we approach 2026, federal agencies are intensifying their focus on the Independent Dispute Resolution (IDR) process, aiming to curb misuse and ensure fairer billing practices. This blog post from Proactive Solutech explores what these changes mean, their implications for hospitals, and how our specialized services can support healthcare organizations in adapting effectively.

What This Means

The No Surprises Act, enacted in 2022, protects patients from unexpected out-of-network bills, especially in emergencies or when ancillary services like anesthesia or radiology are provided at in-network facilities. The IDR process serves as a baseball-style arbitration mechanism where providers and insurers submit payment offers, and a certified entity selects one based on factors like the Qualifying Payment Amount (QPA)—typically the insurer’s median in-network rate.

Heading into 2026, federal agencies are strengthening enforcement around the IDR, with extended discretion on QPA calculations until at least February 1, 2026 (and potentially August 2026). This signals a shift toward tighter rules post-discretion, emphasizing accurate QPA reporting and reducing opportunities for inflated claims. Providers will face stricter scrutiny on out-of-network billing in emergency settings, with the IDR process designed to prevent surprise billing while capping reimbursements closer to market medians. Administrative fees for IDR are also rising, reflecting the system’s overload and the need for hospitals to more rigorously demonstrate that their requested rates align with fair market standards.

How It Impacts Hospitals

These enhancements to the NSA and IDR are poised to significantly affect hospital operations, finances, and compliance efforts. Rising administrative costs, increased scrutiny of QPAs, and the effective cap on charges for emergency and ancillary services (tied to median in-network rates) create new financial pressures. Hospitals must now align pricing with market medians, invest heavily in data analytics to challenge or defend QPAs, and manage prolonged IDR disputes that delay cash flow. The risk of under-reimbursement, higher denial rates, and non-compliance penalties is greater than ever, making precise cost visibility and defensible pricing strategies essential for financial stability.

How Proactive Solutech’s Services Can Help

At Proactive Solutech, we specialize in Time-Driven Activity-Based Costing (TDABC) and advanced cost analytics solutions that give hospitals unprecedented visibility into the true cost of delivering care. Our services directly address the challenges posed by the strengthened NSA and IDR process:

• TDABC Costing & Accurate Cost-to-Serve Modeling: Our proprietary TDABC platform captures the true cost of emergency, anesthesia, radiology, and other ancillary services down to the minute. This granular cost data enables hospitals to build defensible, evidence-based pricing that aligns with market medians while ensuring sustainable margins. By understanding the actual cost of care, hospitals can confidently justify their rates in IDR proceedings and avoid underpayment risks.
• Pricing & Reimbursement Strategy Tools: Our IT platform includes powerful what-if analysis, scenario modeling, and pricing optimization capabilities. Hospitals can simulate IDR outcomes, test pricing strategies against median in-network rates, and determine the most defensible and profitable rates for out-of-network services. This helps minimize revenue leakage and ensures pricing remains competitive and compliant under NSA rules.
• Tracking, Monitoring & Real-Time Insights: Our monitoring tools provide continuous visibility into cost, utilization, and reimbursement performance. Hospitals can track IDR dispute trends, monitor QPA challenges, and identify services at risk of under-reimbursement. This proactive approach allows for timely adjustments to pricing and contracting strategies, reducing the administrative burden and financial exposure associated with IDR.

In an era of tighter regulations and rising IDR costs, Proactive Solutech empowers hospitals with the cost transparency and analytical tools needed to navigate the NSA landscape with confidence. Our TDABC-driven solutions help you defend fair rates, optimize pricing, and protect revenue—turning regulatory challenges into opportunities for financial resilience. Contact us today to see how we can help your organization thrive under the evolving No Surprises Act framework.