A new analysis from HaloMD argues the No Surprises Act has cut out-of-network spending on emergency care by billions of dollars — though, some independent researchers are questioning how the controversial billing middleman arrived at that result.

Out-of-network emergency medical spending has dropped between 13% and 52% since the NSA took effect at the start of 2022, according to the report released Thursday by HaloMD, which contracts with doctors and hospitals to represent them in surprise billing disputes and is one of the most active filers of claims.

The difference between those estimates depends on how payment rates for claims resolved without formal arbitration are pegged. But they equate to annual savings of just below $1 billion to as high as $4 billion across the almost 12 million out-of-network emergency medicine claims subject to the NSA, HaloMD said.

HaloMD’s study comes as providers, raking in the dough from the law’s dispute resolution process, look to head off reform from lawmakers and regulators increasingly interested in curbing perceived excesses from the NSA.

The law, passed in 2020 to shield consumers from surprise medical bills, was expected to reduce healthcare spending by incentivizing out-of-network providers to ink contracts with insurers.

But the mechanism set up by the NSA to settle billing disputes, called independent dispute resolution or IDR, appears to actually be rewarding providers for remaining out of network. Federal data shows that providers file and win the vast majority of IDR claims, and frequently take home payouts well above in-network rates.

HaloMD’s findings are contrary to those from independent think tanks and policy experts, which agree that the NSA appears to jacking up U.S. healthcare spending, mostly as a result of snowballing payouts to doctors.

Last month, for example, researchers with Georgetown University found that IDR generated more than $22 billion dollars in extra spending for the U.S. healthcare system over its first four years.

But the NSA is creating savings overall based on its effect both in and outside of IDR — including the large volume of out-of-network claims that payers and providers settle between themselves without having to enter IDR arbitration, HaloMD argues.

About 90% of out-of-network claims subject to the NSA never make it into arbitration. But most analyses suggesting that No Surprises is spiking spending have looked at IDR results alone, which providers say gives a myopic view of the law’s effects.

A lot of research also uses a metric known as the qualifying payment amount as a stand-in for what an insurer would have paid in-network. Providers believe the QPA is too low, and as a result estimates of NSA costs are overexaggerated. It’s a common refrain from industry groups.

“The data tell a clear story: when the entire out-of-network payment system is considered, arbitration is a small fraction of the whole,” HaloMD CEO Alla LaRoque said in a statement. “Patients are spending less on emergency medical care today because of the No Surprises Act.”

HaloMD’s study, which was penned by the company’s top lobbyist and accompanied by a press release and a Substack post, is an attempt to answer an interesting question: how the law has impacted spending on out-of-network medical care outside of IDR.

But there are fundamental issues with HaloMD’s methodology, according to health policy experts and No Surprises researchers.

For one, the company focused solely on emergency medicine — understandable, given emergency medicine is the largest portion of claims subject to the NSA, Jack Hoadley, a professor with Georgetown’s Center on Health Insurance Reforms and an author of the August study, said.

But it’s also one of the few specialties in which IDR payouts are in the range of prior out-of-network rates, and a significantly lower multiple of the QPA than other specialties.

The median award for emergency services last year was 315% of the QPA, according to Georgetown research. But award amounts soared in other areas. For example, surgery claims were paid out a median of 1,355% of the QPA, and plastic surgery at 3,239% of the benchmark.

“Emergency medicine is actually lower in terms of the typical award levels compared to some of the other specialties out there. We could see some other effects on spending potentially if we look at some of the other specialties,” Hoadley said.

HaloMD also modeled post-NSA spending on claims resolved between insurers and providers outside of arbitration based on the assumption that claims outside of IDR are paid at the QPA or a multiple of it, said Loren Adler, an associate director at the Brookings Institution's Center on Health Policy who closely tracks NSA spending.

“It doesn’t look like there’s actual data at play here,” Adler said. “They’re just sort of making assumptions without any clear basis. And there’s no research design here to draw any casual effect.”

Because of that, it’s impossible to conclude that out-of-network spending outside of IDR is decreasing, he said.

HaloMD’s savings estimate also didn’t account for fees paid to arbiters and other extra costs generated by IDR.

HaloMD, formed in 2022 to help providers submit and win surprise billing contests, has built a lucrative business on the back of NSA disputes. The firm, which earns a percentage of the net payment awards it secures for healthcare providers, initiates more IDR claims than almost any other company — about one-fourth of total disputes — and boasts an IDR success rate of more than 90%.

In 2024, HaloMD received median payouts more than nine times above in-network billing rates for its clients, according to a Georgetown analysis last fall.

HaloMD’s founders, Alla and Scott LaRoque, have enjoyed a lavish lifestyle on the back of the company’s work, according to an investigation from Stat News earlier this year. The company has been accused in multiple lawsuits from insurers of gaming IDR in order to profit. HaloMD has denied all wrongdoing.

Yet HaloMD’s business model could be under threat, as lawmakers and regulators become increasingly critical of the NSA, concerned about outsized provider win rates and egregious award amounts.

The Trump administration finalized a rule this spring meant to make dispute resolution more streamlined and centralized. However, some policies could incentivize providers to file even more disputes, and the rule doesn’t address IDR’s financial incentives, experts say.

Insurers say the rule did not go far enough, and have continued to lobby Congress to reform No Surprises — an outcome companies like HaloMD would prefer to avoid, likely motivating Thursday’s research, Adler said.

“All they’re doing is a broad arithmetic exercise based on ‘ifs,’” Adler said. “Fundamentally I wouldnt read much into the analysis ... Their real motivation is for IDR to survive.”