No Surprises Act IDR: Where Things Actually Stand in 2026

If you were waiting for the long-promised No Surprises Act IDR operations final rule, keep waiting. As of early 2026, the November 2023 proposed rule is still pending. Nothing was finalized in 2024 or 2025 on batching, eligibility, or administrative fees, and the draft is still under Trump-administration review. What we do have is a messier and more important set of developments: a Supreme Court decision that narrowed provider remedies, a massive open-dispute backlog, and a CMS FAQ that extends plan-favorable QPA methodology discretion well into 2026.

What Changed

The developments worth tracking:

Supreme Court declined to review provider enforcement on January 12, 2026. The Court passed on a case that would have addressed whether providers have a private right of action to enforce unpaid IDR awards in federal court. That leaves intact the Fifth Circuit's June 2025 decision, which limits court intervention and pushes providers back to administrative channels when plans do not pay awarded amounts.
QPA methodology discretion extended to October 1, 2026. A 2025 CMS FAQ (Part 73) gives plans continued enforcement discretion to use the 2021 QPA calculation methodology for cost-sharing, disclosures, and IDR submissions through at least October 1, 2026. The practical effect is that plans can continue to calculate QPAs on terms that providers have argued in court are too low.
IDR operations proposed rule still not final. The November 2023 proposed rule on IDR operations — which included stricter batching limits and standardized claim codes — has not been finalized. There was no October 2024 final rule despite earlier expectations.
Backlog reached 430,000 open disputes by June 2025. Volume surged to roughly 3.4 million disputes through June 2025. Payers challenge about 40% of cases as ineligible and certified IDR entities deem about 17% ineligible, which is a major driver of delay.
Two-thirds of disputes blow past the 30-day decision window. In early 2025 data, certified IDR entities are not resolving disputes within the 30-day statutory window in most cases.
2025 CMS guidance formalized a reopening process for disputes closed in error by certified IDR entities.

Why It Matters

For independent practices and facility-based groups that submit IDR disputes, the picture in 2026 is this: you are statistically likely to win when a dispute is actually adjudicated (providers prevail in roughly 88% of adjudicated cases), but you are also statistically likely to wait well past 30 days and face eligibility challenges along the way. And if a plan does not pay an IDR award after you win, your path to enforcement through federal court is now effectively closed.

That has three practical consequences:

Cash conversion from IDR-eligible claims is slow and unpredictable. Do not model these disputes as near-term receivables.
Eligibility documentation matters more than ever. Because payers and IDR entities reject so many disputes on eligibility grounds, the strength of your initial submission — QPA disclosures, open-negotiation documentation, batching rationale — is often what determines whether you ever get to the merits.
QPAs are structurally low for now. Because of the CMS enforcement discretion through October 2026, you are competing against payer-favorable QPA calculations at the bargaining baseline. Expect your out-of-network claim math to look worse than it would if the courts' QPA reasoning were already being enforced.

What to Do

Tighten your 30-day open negotiation records. The single most common reason a dispute is ruled ineligible is documentation gaps around the open negotiation period. Templatize it and make sure every step is time-stamped.
Review batching strategy before every submission. Eligibility rejections on batching are common. Batch conservatively and only when the items clearly share the same plan and items-or-services category until the IDR operations rule is finalized.
Track IDR aging separately from commercial AR. Do not let IDR receivables pollute your standard AR aging. Segment them, forecast them conservatively, and report them to leadership as a distinct bucket.
Use the 2025 reopening process where applicable. If a certified IDR entity closed a dispute in error, CMS has formalized the path to request reopening. It is not automatic — you have to request it.
Pick your fights. With a 430,000-case backlog and no near-term rulemaking, high-volume low-dollar IDR strategies are especially capital-inefficient. Focus on higher-value claims where the math justifies the wait.

Talk to Us

DeltaRCM works with practices and facility groups to build IDR submission workflows that minimize eligibility rejections and maximize the odds of adjudication. If your out-of-network receivables are stuck and you are not sure which disputes are worth pursuing, a short review can map your exposure clearly. Contact us to talk through your NSA strategy.