CMS Denies Recertification to Two Billing Arbiters

The Centers for Medicare & Medicaid Services (CMS) has denied recertification requests from two independent dispute resolution (IDR) entities, Island Peer Review Organization (IPRO) and Network Medical Review Company, according to a Healthcare Dive report published November 6, 2026. These organizations are among the federally certified arbiters that resolve payment disagreements between insurers and out-of-network medical providers under the No Surprises Act. Healthcare Dive reports that insurers welcomed CMS's decision, while critics questioned the impartiality of IDR arbiters more broadly, and both ousted organizations said they were considering an appeal.

The No Surprises Act is a federal law that took effect in January 2022 and generally prohibits out-of-network providers from billing patients directly for the gap between their charge and what an insurer pays, in emergency situations and at certain in-network facilities. When a provider and an insurer cannot agree on a fair payment amount for one of these claims, either party can escalate the dispute to an independent arbiter through the IDR process. The arbiter reviews both sides' proposed payment amounts and picks one, a decision that is supposed to be binding and neutral.

The available reporting does not specify the exact grounds CMS cited for denying recertification to IPRO or Network Medical Review. It is not yet clear whether the decision reflects documented performance problems, procedural violations, policy disagreements over how the two entities weighed provider charges versus insurer benchmarks, or some combination. Readers should treat the "impartiality" question raised by critics as a characterization from the source reporting rather than a confirmed CMS finding, since CMS's stated rationale has not been detailed publicly as of this writing.

Key Takeaway

The No Surprises Act does not apply to Original Medicare or most Medicare Advantage claims, because federal law already exempts those programs and gives them separate billing and network rules. This CMS personnel decision mainly affects people with employer group plans, COBRA coverage, or Affordable Care Act marketplace plans, which includes many people in the years just before Medicare eligibility. If you are approaching 65, it is still worth understanding how surprise billing protections differ between your current coverage and Medicare before you enroll.

Why Insurers and Critics Are Split

Insurers have argued for years that some IDR arbiters lean toward providers' billed charges rather than insurers' calculated "qualifying payment amount," which insurers say drives up claim payouts and, over time, premiums. Provider groups and some lawmakers have made the opposite argument, saying CMS's underlying IDR formula already tilts toward insurers' lower benchmark figures. CMS's decision to deny recertification to two specific arbiters lands squarely inside that ongoing fight, which is why insurers cheered the move while critics raised impartiality concerns, per Healthcare Dive. Neither the specific dispute volume handled by IPRO and Network Medical Review nor the appeal process timeline was detailed in the available reporting.

What This Means for Medicare-Focused Readers

Original Medicare sets its own payment rates and limits what providers can charge beneficiaries, so Medicare claims are not routed through the No Surprises Act's IDR process at all. Medicare Advantage plans operate under separate CMS network adequacy and billing oversight, and MA enrollees already generally owe only in-network cost sharing, with their own emergency care billing protections built into MA program rules rather than the No Surprises Act. For most people already on Medicare or Medicare Advantage, this specific CMS action has no direct effect on their claims.

The relevance for this site's audience is more indirect, but still real for two groups. First, anyone still covered by an employer group plan, COBRA, or an ACA marketplace plan in the years before turning 65, including spouses and dependents under 65 on a retiree health plan, could have a dispute resolved by the remaining certified IDR arbiters, so the composition of that arbiter pool matters to them directly. Second, CMS's willingness to remove certified arbiters over disputed conduct is a signal about regulatory posture. It shows CMS is prepared to intervene in how billing disputes get decided, which is useful context if CMS later revisits any Medicare Advantage billing dispute or network adequacy processes, even though those run on separate authority from the No Surprises Act.

Practical Steps If You're Nearing Medicare Eligibility

If you are within a few years of turning 65 and currently rely on an employer plan, COBRA, or a marketplace plan, keep your Explanation of Benefits (EOB) statements and know that you can file a complaint through the federal No Surprises Help Desk if you receive an unexpected out-of-network bill that you believe should be covered under current protections. This process exists independently of which specific arbiters are certified at any given time.

Once you do enroll in Medicare, compare how billing works under Original Medicare with a Medigap policy versus a Medicare Advantage plan, since the two paths handle out-of-network costs and provider billing differently, and that difference matters more for your out-of-pocket exposure than changes to the No Surprises Act's arbiter roster. A licensed insurance agent can walk through how each option would apply to your specific providers and prescriptions. For the latest details on CMS's decision and any appeal outcome, see the original Healthcare Dive report, and watch for CMS follow-up statements that may clarify the agency's specific rationale.