A federal arbitration system created under the No Surprises Act has cost more than $22 billion in payments to medical providers and related costs since 2022, according to a Georgetown University analysis published Aug. 26 in Health Affairs Forefront. The bill for this little courtroom for insurers and providers keeps climbing, while patients are told they’ve been “protected” from surprise charges and still get stuck with copays, coinsurance and deductibles.
Who Pays for the Fight
The Georgetown analysis said the system cost $16.6 billion in 2025 alone, more than triple the amount paid in 2024, and that from 2022 through 2025 the total price tag reached $22.4 billion in extra awards, arbitrator fees and administrative expenses. That money doesn’t come from nowhere. Jack Hoadley, a research professor at Georgetown’s Center on Health Insurance Reforms and a co-author of the analysis, said the system has failed to meet its cost-containing goal. He said enormous arbitration costs inevitably add to the insurance premiums paid by consumers, and that some employers have already attributed a portion of their premium increases to arbitration costs. Hoadley said, “We’re definitely concerned about downstream impacts on premiums.”
The No Surprises Act, passed by Congress in 2020, was sold as a shield for patients facing emergency room bills and pricey air ambulance rides. The law removed patients from billing disputes, but not from the bill itself. They still must pay the copays, coinsurance and deductibles required by their insurance plan. The state and the insurers can argue over the rest. Ordinary people still pay.
The Arbitration Machine
Since arbitration began in 2022, doctors have won a vast majority of cases. In 2025, medical providers won 85% of disputes and were awarded payments more than four times the qualifying payment amount, defined as the median contracted in-network rate for care, according to the analysis. Medical providers brought 2.6 million disputes in 2025, up 77% from 2024, far above the federal government’s initial estimate of about 22,000 disputes per year. The analysis said payments jumped 264% from 2024 in 2025.
That’s not a small administrative hiccup. It’s a machine. The federal government set it up, and the numbers show who learned to work it. Doctors who are not satisfied with the amount an insurance plan offers can seek baseball-style arbitration, in which the arbitrator must choose either the insurer’s proposed payment or the medical provider’s request and cannot split the difference. The setup rewards escalation, not restraint.
The Georgetown analysis found more than three-fourths of awards involved three physician and middleman organizations: Radiology Partners, HaloMD and TeamHealth. HaloMD, which files disputes on behalf of providers, is the largest middleman organization involved in arbitration cases. The analysis said HaloMD has boasted of winning $2 billion in award determinations for provider clients and won 90% of cases. In a statement, HaloMD’s Chief External Affairs Officer Patrick Velliky said the company facilitates access to sustainable reimbursement for more than 27,000 doctors and clinicians nationwide and is proud to help provide the means for those groups to remain independent and continue serving their communities.
Radiology Partners said in a statement that the Georgetown analysis missed the mark by failing to address the underlying factors driving physicians to request arbitration in the first place. The company quoted a judge who cited insurers’ lowball offers to out-of-network providers in an effort to maximize profits. That’s the whole rigged dance: insurers squeeze, providers counter, and the public gets the premium hike.
Premiums, Budgets, and the People Stuck Below
The analysis cited examples of insurers raising rates. The New York state budget document said out-of-network providers are using arbitration under the No Surprises Act and similar state legislation to maximize revenue, that arbitration added more than $200 million in claim payments to the health insurance plan for state employees and families, and that the awards were a primary contributor to the 2027 state health plan’s premium increase of nearly 10%. The Georgetown analysis also cited a United Service Workers union plan that raised premiums another 1.75 percentage points to offset arbitration awards and fees, and a United Healthcare official who said arbitration added 2% to 6% in premium expenses for privately insured customers.
So the costs get pushed downward, as they always do. State employees and families, union plan members, privately insured customers — all of them end up paying for a dispute system built inside the same hierarchy that created the mess. The law may have removed patients from the formal billing fight, but it left them inside the financial blast radius.
A survey released earlier this month reported that more than 4 in 10 adults cited the cost of health insurance as the biggest problem that needs to be fixed in the U.S. health care system. People also complained about the amount they spend on copays and deductibles for medical bills, lab tests and prescription drugs. That’s the part the polished language can’t hide. The system keeps inventing new ways to charge people, then calls it reform.