CMS Denies Recertification for Two Billing-Dispute Arbiters

The Centers for Medicare & Medicaid Services (CMS) denied recertification requests this week for two companies that arbitrate out-of-network billing disputes under the federal No Surprises Act, according to a report by Healthcare Dive. The agency removed Island Peer Review Organization (IPRO) and Network Medical Review Company (NMR) from the program. Insurers welcomed the decision, while both companies said they are considering an appeal, and critics have questioned whether the move compromises the impartiality of the dispute resolution system.

What the No Surprises Act and IDR Process Actually Do

The No Surprises Act is a federal law that took effect in January 2022 and generally bars out-of-network providers from billing patients directly for emergency care and certain non-emergency services performed at in-network facilities. When an insurer and an out-of-network provider cannot agree on a payment amount, the law sends the dispute to an Independent Dispute Resolution (IDR) entity: a CMS-certified arbiter that reviews both sides' final offers and picks one. IPRO and NMR were two of the certified IDR entities handling these cases until CMS declined to renew their certification this week, per Healthcare Dive's reporting.

CMS has not published a detailed public explanation for the denials, and Healthcare Dive notes both companies may appeal. The story does not specify a replacement timeline for the caseload these two arbiters were handling.

Key Takeaway

This CMS decision affects the No Surprises Act arbitration system used by employer-sponsored and marketplace health plans, not Original Medicare or Medicare Advantage billing. Medicare already sets its own federal limits on what non-participating providers can charge beneficiaries, separate from this dispute.

Why Insurers Cheered and Providers Are Watching Closely

Insurers have argued for months that some IDR entities ruled in providers' favor too often, driving up payouts that insurers say eventually show up in premiums. Provider groups have made the opposite case, saying insurers routinely submit lowball offers and rely on a process tilted toward their side. Removing two arbiters that handled a meaningful share of disputes could shift outcomes across the system, though the real-world effect depends on which certified entities absorb IPRO's and NMR's pending caseload. Critics quoted in Healthcare Dive's reporting have raised the broader concern that decertifying arbiters based on their ruling patterns, rather than procedural problems, could erode confidence that the IDR process is neutral.

Why Medicare Readers Should Still Pay Attention

Medicare Plan Path readers should know the No Surprises Act and its IDR process generally do not apply to Original Medicare or Medicare Advantage claims. Original Medicare already limits what non-participating providers can charge, capping excess charges at 15% above the Medicare-approved amount under existing federal rules, and Medicare Advantage plans operate under their own CMS-regulated network and billing requirements. The arbitration fight described in this story centers on private group health plans and marketplace coverage, not Medicare.

That said, the episode is still relevant to Medicare households in a few practical ways. If you or a family member under 65 has employer coverage or a marketplace plan, this dispute over arbiter impartiality could influence how billing fights over emergency or out-of-network care are resolved, and potentially how insurers price premiums going forward. If you are approaching 65 and weighing Medicare Advantage against staying on an employer plan or COBRA during open enrollment, it is worth asking each option how it handles out-of-network billing surprises, since the protections and dispute processes differ by coverage type. And regardless of which program you are in, confirming a provider is in-network before scheduled, non-emergency care remains the most reliable way to avoid a billing dispute altogether, since No Surprises Act protections apply only to specific situations like emergencies and certain ancillary services at in-network facilities.

CMS has not said whether it will apply similar scrutiny to oversight of other CMS-run programs, including Medicare Advantage network adequacy reviews. For now, this story is about the No Surprises Act specifically, and Healthcare Dive reports the outcome is not final while IPRO and NMR consider their appeal options. Readers comparing Medicare Advantage, Medicare Supplement, or Part D plans should continue to review plan networks and billing rules directly with a licensed agent or through Medicare.gov, since this particular dispute does not change those rules today.