Which providers are exempt from the No Surprises Act arbitration (IDR) process?
Executive summary
Federal No Surprises Act (NSA) protections remove patients from billing disputes and generally route payment disagreements between out-of-network providers and health plans into the Independent Dispute Resolution (IDR) process; however, the law’s scope and procedural rules have evolved through agency guidance, litigation and agency discretion, and available sources do not list a simple universal roster of “exempt” providers from the federal IDR process (available sources do not mention a definitive exemption list) [1] [2] [3].
1. Who the law covers—and why “exempt” isn’t a short list
The NSA bars balance billing for certain emergency services and many non‑emergency services at in‑network facilities, and it establishes the federal IDR process to resolve payment disputes between out‑of‑network providers/facilities and plans—i.e., it is designed to keep patients out of the middle [1] [4]. Sources emphasize that the statute applies broadly to hospitals, facilities, individual practitioners and air ambulance providers for covered circumstances, so the concept of an “exempt provider” is context‑dependent rather than a single named set of entities [5] [6].
2. State law, ERISA and the preemption wrinkle
An important exception to federal reach is where state law already sets a binding payment amount or dispute process for state‑regulated plans: in those cases, state law can preempt the federal IDR mechanism. Self‑funded employer plans governed by ERISA are federally regulated and generally fall under the NSA’s federal protections, but the interaction of state rules versus federal authority creates practical carve‑outs depending on plan type and local law [7] [4].
3. Specific service categories that have been contentious (air and ground ambulance)
Air ambulance providers are explicitly named as covered by the NSA’s balance‑billing prohibition in multiple summaries and agency resources, and they therefore fall within the dispute framework for covered claims [5] [6]. Ground ambulance coverage has been contentious: several states have moved to regulate or block balance billing for ground ambulance locally, producing a patchwork of protections and leaving federal versus state applicability subject to legislative and regulatory developments [8] [4].
4. Litigation and agency discretion have shifted who participates in IDR
Post‑enactment litigation—most notably the Texas Medical Association cases—and subsequent FAQs and enforcement discretion from the Departments have changed how the IDR process operates, which affects eligibility and timing for submissions rather than creating categorical new exemptions for specific provider types. CMS and the Departments have issued FAQs and periods of enforcement discretion tied to methodologies for calculating the QPA (qualified payment amount), and those actions have influenced which disputes proceed to IDR and under what rules [2] [3] [9].
5. Practical exemptions: when a dispute won’t go to federal IDR
Available sources show practical reasons a claim won’t go through federal IDR: if state law already prescribes a payment amount or dispute process for the plan involved; if parties opt into state‑level processes where applicable; or if the services or plans are outside the statutory categories (for example, some non‑covered provider billing situations). But sources do not provide a single authoritative list of provider types that are categorically exempt nationwide [7] [4] [6].
6. How implementation rules and proposed 2025 changes matter to providers
The federal IDR process has technical eligibility and procedural requirements that can exclude specific disputes on administrative grounds (timing, proper notices, QPA calculations, or failing to meet other notice/consent rules). Proposed and final rule updates in 2024–2025 sought to tighten eligibility timelines and document rules, meaning that some providers may find disputes rejected for procedural rather than substantive “exemptions” [10] [2].
7. Competing perspectives: patient protection vs provider concerns
Advocates for the NSA present the IDR process as a patient‑protection mechanism that shifts payment fights away from consumers [1] [4]. Providers and some industry analysts say litigation, ambiguity in QPA methodology, and administrative rules create loopholes or operational burdens that can effectively limit access to IDR or incentivize strategic filing patterns; sources document ongoing legal challenges and criticism that providers file in bulk to chase higher awards [11] [12].
8. What reporters and stakeholders should watch next
Because sources show the law’s contours have changed through FAQs, court decisions and agency discretion rather than by simple statutory carve‑outs, the next key indicators are: finalized 2025 IDR rules; any Supreme Court or circuit court mandates altering the Departments’ guidance; and state legislative activity on ambulance and other services. Those developments will determine which providers can or cannot use the federal IDR pathway in practice [2] [3] [8].
Limitations: available sources do not provide a single, definitive list of provider types categorically “exempt” from the federal IDR process; my reporting here is limited to the documents and analyses supplied [1] [2] [4] [3] [6] [5].