When President Donald Trump signed the No Surprises Act, he delivered a real victory for American patients. For the first time, families couldn’t be ambushed by crippling out-of-network bills after an emergency they never chose. It was the commonsense, pro-patient reform Washington had promised for decades and never delivered. Trump got it done.
But a law is only as good as its implementation. The Biden administration failed to implement it properly, leaving loopholes that benefit their friends and donors in the hospital industry. Bureaucrats and well-funded special interests turned one of Trump’s signature healthcare achievements into a money machine at the expense of the families it was meant to protect.
The culprit is the law’s arbitration system, the Independent Dispute Resolution process. Designed as a last resort to settle payment fights between insurers and out-of-network providers, it has instead been captured by a handful of private equity-backed provider groups and arbitration “middlemen.” There have been roughly 1.2 million disputes in just the first half of 2025 — more than double the year before, and far beyond the 17,000 annual disputes regulators originally projected. Providers now initiate 99.9% of all cases and win 88% of them, routinely collecting three to nine times the in-network rate. Some groups’ awards exceed more than 900% of the benchmark price.
Outrageous examples abound. Plastic surgeons advertising $25,000 breast reduction surgeries filed an IDR claim for $600,000 and were awarded $440,000. Another provider claimed $2,872 to treat a runny nose — more than seven times the median fee. A health plan’s standard $2,660 payment offer for a blood flow diagnostic procedure turned into a $333,000 award. Providers are winning awards of 600 times the usual rate for IUD procedures. The list goes on, and we all pay for it.
This is not the free market at work. It’s a rigged game. Out-of-network doctors and IDR middlemen have learned that volume plus a friendly arbitrator equals a windfall. Arbitrators only get paid when a claim proceeds, so they’re largely incentivized to let facially invalid claims go through. In fact, nearly 40% of disputes filed in 2024 were for ineligible claims, yet half still resulted in payment.
In the first half of 2025, just four entities accounted for 56% of all IDR claims. This is what the vice president’s anti-fraud task force would likely call a “big red flag.” A third-party billing industry has emerged that inflates claims, adds collection costs, and floods the system with ineligible claims, costing patients billions. Some providers now share ownership with IDR claims companies, further proof of how central gaming the system has become to their business model.
The result is over $5 billion in total IDR-related costs in just two years, and the figure is climbing.
IDR abuse is a growing driver of rising healthcare costs for the public. Workers and employers bear that cost. New York’s state employee plan traced more than $200 million in excess payments to this abuse, a major driver of its nearly 10% premium jump. A union health fund covering 20,000 tradesmen had to hike premiums to keep up.
The Trump administration’s recent surprise billing reforms made the IDR process more efficient but didn’t fix the core problem. The loopholes remain, and they’re still being exploited. The swamp adapted. Now it’s time to drain it.
FLYING ICUS ARE ON LIFE SUPPORT — THIS MEDICARE REFORM IS THE CURE
The fixes are straightforward: restore the qualifying payment amount — the market median rate — as IDR’s true anchor, removing providers’ incentive to stay out-of-network for outsized payments. Screen out ineligible claims before they clog the system. Hold arbitrators to real performance standards and end conflicts of interest so no firm owns both a provider group and the “neutral” entity judging its cases. Charge a fair upfront fee and penalize abuse.
The president fought to protect patients from predatory billing. Private equity and the bureaucracy have hijacked that protection. It’s time to end this legalized fraud, fulfill the No Surprises Act’s promise to lower healthcare costs for people, and once again show families that the Trump administration is always on their side.
West Cuthbert, director of American Resolve, previously served as associate deputy secretary at the U.S. Department of Health and Human Services, where he helped oversee policy and operational initiatives across the department.