In the first year of the federal Independent Dispute Resolution process under the No Surprises Act April 2022 through March 2023 more than 300,000 disputes were initiated. Federal agencies had projected roughly 17,000. The actual volume came in at nearly twenty times that estimate, and the backlog has not cleared.
Ambulatory surgery centers are explicitly named as participating health care facilities under the NSA. That means out-of-network determinations at an ASC trigger the same patient protections, the same open negotiation period, and the same IDR escalation path that hospitals face. The administrative load is not optional and not delegable.
Why the volume is so high
Three structural factors drove the overage. First, the qualifying payment amount methodology produced lower initial payer offers than providers expected, pushing more cases into negotiation. Second, batching rules let providers consolidate similar disputes, which inflated dispute counts even when the underlying claim volume was steady. Third, payers and providers had no operational muscle memory for the process, and the early months produced a flood of disputes that should have settled in open negotiation.
Provider win rates in 2023 determinations have run in the neighborhood of 80 percent. That number is striking, but it is misleading without context. The providers prevailing are the ones who arrived at IDR with organized documentation. The ones who did not, generally did not file.
What the IDR entity actually wants to see
The certified IDR entity is required to consider the qualifying payment amount and may consider additional credible information submitted by either party. For an ASC, the credible information that matters falls into four buckets:
- The fully executed payer contract, if one exists, and the relevant fee schedule with effective dates
- Documentation of the open negotiation period dates, offers, counteroffers, and communications
- Evidence of the level of training, experience, and quality of the provider, and the market rate for the service in the geography
- The acuity of the patient, complexity of the case, and any factors distinguishing it from a routine encounter
Each of these buckets is a documentation problem before it is a dispute problem. A center that cannot produce the fee schedule that was in effect on the date of service is not going to win on the merits, regardless of how strong the underlying case is.
The contract problem
ASCs typically hold contracts with a dozen or more payers, each with different amendment cadences, different fee schedule attachments, and different out-of-network provisions. Finding the version of a contract that was in effect on a specific date of service, two years after the fact, is the part that breaks most centers.
The discipline required is unglamorous: every contract version stored with effective and termination dates, every amendment linked to its parent agreement, every fee schedule attached to the contract version it modifies. Done well, an IDR submission becomes a half-day of evidence assembly. Done poorly, it becomes a week of email archaeology and a missed deadline.
Quick win
Pick your three highest-volume payer relationships. For each, can you produce in under ten minutes the contract version, fee schedule, and amendment history in effect on a random date six months ago? If not, that is your first IDR vulnerability.
The vendor and clearinghouse angle
IDR submissions live and die on dates. The date of service, the date the initial payment or notice of denial was received, the open negotiation window, the IDR initiation deadline. Most ASCs route these communications through a clearinghouse or billing vendor, which means the source of truth for when did we receive notice sits in someone else system.
Centers need a documented data feed or report from each vendor that establishes these dates with audit-grade reliability. A screenshot from a billing portal is not evidence. A timestamped report from the vendor of record, retained per the center record retention policy, is.
What this means operationally
The NSA is not a temporary regulatory bump. The volume of disputes is normalizing higher than agencies expected, and the dispute-resolution process is now a permanent feature of ASC revenue cycle operations. Centers that treat it as a one-off legal exercise will continue to leave money on the table or, worse, generate findings during payer audits.
The centers that are winning are the ones that built a documentation operation behind the dispute process, not the ones that hired a better attorney.
How DocForms helps
Contract Management stores every payer contract version with effective dates, links amendments to parent agreements, and attaches fee schedules to the specific contract version they govern. Pulling the document set in effect on any given date becomes a query, not an archaeology project.
Vendor Management tracks the billing vendors and clearinghouses that mediate payer communications, with the audit reports and SLAs needed to substantiate dates of notice in an IDR filing.
Compliance Logs records the open negotiation timeline, IDR initiation dates, and determination outcomes in one place, so the center has both a defensible record per dispute and the aggregate data needed to identify which payers and which service lines are driving volume.