Each quarter, CMS publishes Federal IDR Public Use Files that provide a retrospective view into how the No Surprises Act dispute process is functioning. These datasets are released with a lag. For context, Q4 2024 data was published in May 2025, while Q1 and Q2 2025 data was released in
January 2026.
That timing matters. The data reflect past behavior, and organizations may have adjusted internal processes based on trends they are seeing ahead of CMS publication. Even so, when I look across three consecutive quarters of data (Q4 2024, Q1 2025, and Q2 2025), the directional signals are consistent.
In short: the Federal IDR process is scaling, and the scale itself is shaping behavior, outcomes, and operational risk across the ecosystem. The shift is clear: IDR is not a dispute resolution mechanism, it is operational competition.
Below are four insights from my analysis. But first, full disclosure: Macedon makes an Award-winning NSA Automation Software. Schedule a chat with me if you would like to know more.
The growth story is unmistakable. After accelerating by 14% between Q4’24 and Q1’25, disputes exploded by 34% in Q2’25. Nearly all of this growth came from out-of-network emergency and non-emergency services, which increased by roughly 35% during this period.
Contrast that to air ambulance disputes, which declined modestly by 8.8% (11,581 in Q4’24 to 10,560 in Q2’25). This divergence suggests the next wave of IDR pressure will not come from historically complex or niche categories but instead, from high-volume, repeatable service lines where providers can standardize disputes at scale.
Why This Matters: The data indicate that the IDR system is no longer being tested primarily by edge cases, but is being exercised by the economics of volume.
Facility-initiated disputes increased from just under 62,000 in Q4 2024 to 147,000+ in Q2 2025, a massive 138% jump in just three quarters. As a result, facilities’ share of total disputes rose from 13% to nearly 23%.
This cannot be accidental growth.
Hospital systems are clearly institutionalizing IDR as part of core revenue cycle operations. The presence of organizations like Prime Healthcare, which filed 14,000+ disputes in Q4’24 and remained among the top in Q2’25, underscores that IDR is increasing managed as an enterprise workflow, not an episodic appeals function.
Why This Matters: This reflects a structural change in how IDR is managed. It’s reasonable to assume that large health systems are beginning to (or continuing to) centralize dispute intake, standardize documentation, and are treating the dispute process as a repeatable revenue cycle workflow rather than an exception process.
Across all three quarters, outcomes remained remarkably consistent despite rising dispute volumes. 84.3% of determinations exceeded QPA in Q4’24, which increased to 87.5% in both Q1’25 and Q2’25. Interestingly, during the same period, the total number of determinations increased by 56% - showing the high rate continues to scale regardless of the number of claims submitted.
This combination helps explain continued filing growth. When nearly nine out of ten determinations land above QPA, the economics of using the dispute process remain compelling. This is particularly noteworthy for those organizations that have already lowered the cost and friction of dispute submission.
Why This Matters: The stability of outcomes over the past three quarters, at scale, will always reinforce behavior. In other words, I expect dispute volumes will continue at this trajectory if dispute outcomes continue to incentivize behavior.
One of the clearest stress signals in the data shows up not in win rates, but in non-participation. Across three quarters:
For a few payers, we’re seeing a stark gap in behavior:
Why This Matters: For payers and providers, the differentiator is operational discipline and efficiency. Executing on the organizations’ dispute process (or not executing on it) is unmistakably shaping dispute outcomes even before the arbitrator weights in.
Using data as our north star, it’s clear that one of the most important takeaways is not that IDR volume is growing but how organizations are responding to that growth.
The data increasingly suggests that IDR outcomes are more likely to be shaped by operational execution as it is by interpreting the QPA formula. Organizations that treat IDR as a governed workflow, with disciplined intake, deadline tracking, documentation standards, and auditability, are pulling far ahead of those that rely on manual processes or fragmented systems, which will continue to be exposed to the growth in dispute volumes.
In that sense, the message is clear: the Federal IDR is not solely about statute anymore. It’s about how well organizations execute at scale.
Looking ahead, as I continue to review the upcoming CMS reports, there are two other developments that I am keeping my eye on:
First, CMS is expected to continue refining operational guidance through the IDR Operations Rule, including clarifications around eligibility review, batching, and administrative processes as part of broader 2026 implementation efforts.
Second, there is growing attention on HR 4710, the No Surprises Act Enforcement Act, which could affect oversight, compliance expectations, and enforcement posture across the IDR ecosystem for both payers and providers.
Want to continue the discussion? Schedule a chat with Seth.