KPMG flags major changes to No Surprises Act dispute process

KPMG is flagging the No Surprises Act dispute overhaul as an operations change, not just a compliance update. The federal independent dispute resolution process, which launched in April 2022 and has already taken in more than 5 million disputes, will now run under new rules finalized May 28 by the Department of Health and Human Services, the Department of Labor, the Department of the Treasury and the Office of Personnel Management.

The biggest immediate shift for providers, payers, air ambulance operators and certified IDR entities is procedural. The rule streamlines communication between payers, providers and certified IDR entities, clarifies timelines and procedures, and pushes more of the eligibility screening upstream by requiring new payer disclosures using claim adjustment reason codes and remittance advice remark codes at the initial payment or denial stage. That means fewer disputes should make it into the system by mistake, but the work before filing just got more exacting: intake teams, coding specialists, revenue-cycle staff and outside advisers will need tighter controls over remittance advice, denial letters, open-negotiation records and submission packets.

The economics of filing also changed. The federal administrative fee falls from $115 to $15 per party per dispute for disputes initiated on or after June 11, a reduction of 87 percent. The separate certified IDR entity fees do not change, so organizations will still need to budget for contractor-specific costs. For smaller practices, the lower federal fee removes a barrier to entry, but it also means more parties may be willing to test the process, which could keep pressure on providers’ and insurers’ case-management teams even as the system becomes cheaper to access.

For KPMG professionals, the impact reaches beyond healthcare clients. Benefits teams, health-plan advisers and transaction teams all touch the economics of self-insured arrangements, reimbursement expectations and contracting. The practical question now is which disputes are eligible, how much friction the new process removes and where internal controls need to be retooled so claims can withstand faster review. That points directly to workflow redesign inside finance, compliance and advisory groups, especially where teams have been relying on manual review or inconsistent coding.

The rule does not change the underlying qualifying payment amount methodology or the broader coverage scope of the No Surprises Act, enacted in 2020. It does, however, change how disputes move. The American Hospital Association said the new framework improves functionality, including batching up to 50 items and services in one payment dispute, while the Medical Group Management Association said the fee cut should make IDR more accessible, especially for smaller practices. For firms serving healthcare clients, the real work starts now: less policy watching, more process redesign.