Litigating the No Surprises Act: how legal challenges undermined cost containment and reshaped provider payments

The No Surprises Act (NSA), signed into law by President Trump over five years ago, marked a significant federal intervention aimed at shielding millions of consumers with private health coverage from unexpected out-of-network medical bills. While the Act is lauded for successfully protecting consumers, its implementation has been plagued by aggressive litigation, with provider-led lawsuits challenging the Act itself as well as every rule issued to implement the protections and countless other lawsuits challenging actions (or inactions) by providers, insurers, and independent dispute resolution (IDR) entities. This litigation has profoundly impacted the Act's cost-saving objectives by eroding its payment methodology and fostering extensive use of the IDR process. This paper chronicles the litigation timeline from the passage of the NSA through April 2026 and its impacts on the implementation, detailing the challenges to the regulatory framework and how adversarial legalism shaped the NSA's trajectory. The paper concludes by offering policy options for Congress, federal agencies, states, and stakeholders to reduce costs and IDR volume to better align with the intent of the NSA.