Federal Regulators Decertify Two Surprise Billing Arbitrators Citing Performance Failures

Federal regulators have denied recertification to two of the 17 certified arbitration firms that resolve surprise billing disputes between healthcare providers and insurers, removing them from the No Surprises Act process. The Departments of Labor, Health and Human Services, and the Treasury determined that Island Peer Review Organization (IPRO) and Network Medical Review Company “failed to meet required minimum performance standards,” according to the American Hospital Association. The decision was disclosed on November 4.

IPRO ruled in favor of providers approximately 97% of the time—the highest provider win rate among arbiters—according to data from price transparency firm Turquoise Health, as reported by Healthcare Dive. Network Medical Review sided with providers about 70% of the time, lower than many of its peers.

Neither firm can accept new disputes, and both said they are considering an appeal. For patients, the change does not affect the law’s core protections. However, it is an enforcement action aimed at the arbiters themselves—the referees in a system whose payouts insurers say eventually show up in premiums.

Update Note: This article reports new information on the No Surprises Act arbitration process following earlier coverage. Latest verified update: CMS list of certified independent dispute resolution entities, last modified November 4, 2026, and agency notices reported November 5 and 6, 2026.

Two Arbiters Lose Their Certification

The agencies did not publicly detail what each firm did wrong. Federal guidance lists possible grounds for denial, including late decisions, inaccurate eligibility or payment determinations, and conflicts of interest. To stay certified, arbiters must meet standards for “timeliness, accuracy, and independence and impartiality,” CMS wrote.

The federal list of certified organizations now labels both firms as not accepting new disputes. Parties with cases still open before them will receive additional guidance from the agencies. Appeals must be filed within 30 days.

Both firms pushed back. IPRO said it was “disappointed” with the decision, and Network Medical Review said it was confident in its work. Healthcare Dive noted that Network Medical Review granted half of a $440,000 breast reduction payout reported by The New York Times.

Since Earlier Reporting on 2.9 Million Disputes

Previous reporting indicated that the arbitration system, built for about 17,000 disputes a year, logged nearly 2.9 million disputes through September, and critics warned provider-friendly awards could push up premiums. That report focused on volume and overall outcomes, with providers prevailing in about 85% of payment decisions.

The new development shifts the focus from the system’s size to the referees inside it. Regulators have now removed two arbiters, and one of them had a provider win rate well above the system-wide figure of more than 85% last year.

The two firms were not minor players. Both have served for about five years and settled hundreds of thousands of disputes, Healthcare Dive reported. IPRO’s revenue nearly tripled during its arbitration work, according to a Stat News investigation cited in the same report. Officials are also reviewing petitions to deny recertification to eight more entities, which could reshape who decides the bulk of disputes.

Patient Protections Stay in Place

The No Surprises Act protects most patients from surprise bills for emergency care and for certain out-of-network care at in-network hospitals and surgery centers. In those cases, patients owe only their usual in-network cost-sharing, and the payment fight happens between the provider and the insurer. That protection does not change with this decision.

The arbitration process can affect families indirectly. Insurers and employers argue that high arbitration awards are passed on through premiums. The Coalition Against Surprise Medical Billing, which represents insurers and employers, praised the decision and asked CMS to pause all recertifications.

Providers see it differently. Physician groups have argued that insurers often underpay out-of-network claims and that arbitration is the main way doctors can win fair payment. Arbiters earn $425 to $800 per case and nothing for disputes ruled ineligible, which researchers say creates an incentive to find cases eligible.

People most affected by the broader debate include workers in employer plans, people buying their own coverage, and small businesses facing rising premiums. Patients in states with their own surprise billing laws may see some disputes handled under state processes instead.

Steps If a Surprise Bill Arrives

Patients who receive a bill that seems to violate the law should not pay it right away. They can compare it with their insurer’s explanation of benefits, ask the provider and insurer for an itemized account, and call the federal No Surprises Help Desk at 1-800-985-3059. Keeping copies of bills, notices, and any consent forms helps if a complaint is needed.

People without insurance or paying out of pocket are entitled to a good faith estimate before scheduled care and can dispute a bill that comes in at least $400 higher than that estimate.

The next steps to watch are whether IPRO or Network Medical Review files an appeal, what happens to disputes still pending before them, and how regulators rule on the eight other petitions. Congress is also weighing changes, including a bill from Rep. Frank Pallone Jr. that would eliminate the arbitration process.

Key Questions Answered

Which arbiters were removed? Island Peer Review Organization (IPRO) and Network Medical Review Company.

Why were they decertified? Regulators said both failed to meet required minimum performance standards. Specific findings were not released.

How often did IPRO side with providers? About 97% of the time, according to Turquoise Health data.

Can the firms appeal? Yes. Appeals must be filed within 30 days, and both firms said they are considering one.

Does this change my surprise billing protections? No. Patients remain protected from most surprise bills and owe only in-network cost-sharing.

Where can I report a surprise bill? Call the No Surprises Help Desk at 1-800-985-3059.

Source link