When Congress passed the No Surprises Act (NSA), the goal was clear: protect American patients from outrageous surprise medical bills. But less than three years later, the very process designed to shield patients, the Independent Dispute Resolution (IDR) system, has become a profit engine for foreign governments and private equity giants.
According to federal data, Radiology Partners was one of the top initiators of IDR disputes nationwide in 2024. This isn’t your local doctor; it’s a corporate powerhouse backed by a private equity firm, a venture capital fund, and the Australian sovereign wealth fund. In other words, a foreign government is now using a U.S. healthcare arbitration system to extract higher payments from American insurers and, ultimately, from American patients and employers.
They’re not alone. TeamHealth, the number one IDR filer in 2023, is owned by Blackstone, two major Canadian pension funds, and the National Pension Service of Korea. Another major player, Envision Healthcare, was among the top filers in every quarter of 2023. Envision has been owned by private equity giant KKR since 2018 through a fund backed by public pensions from Iceland, Switzerland, and the United Kingdom.
Taken together, this means that billions of dollars flowing through the No Surprises Act’s arbitration process are being fought over, and often won, by investment funds and foreign governments. These entities were never the intended beneficiaries of the law. The NSA was meant to stop surprise bills and stabilize costs, not to enable global financiers to wage billing wars for profit inside our healthcare system.
The IDR process was conceived as a safeguard for patients, not a new frontier for speculative investment. Yet in practice, it has become an extension of the same “buy and bill” model private equity introduced into emergency medicine and radiology years ago: buy local practices, consolidate contracts, and use out-of-network leverage to demand higher payments. Now, when insurers refuse, these firms take thousands of cases to arbitration, clogging the system and driving up administrative and legal costs across the healthcare economy.
And hospitals allow it all to happen. When a patient chooses an in-network hospital, they should be able to trust that their care team, from the emergency physician to the anesthesiologist, will also be in network whenever possible. That shouldn’t depend on luck or paperwork. It should be built into how hospitals and health plans do business.
Congress and regulators should take note. The Department of Health and Human Services and the Department of Labor must examine who is actually benefiting from IDR and whether foreign sovereign entities should be permitted to profit from a program created to protect American patients. Transparency requirements should include not only ownership disclosures but also the nationality of ultimate beneficiaries. Additionally, hospitals must change their behavior to prevent this cottage industry from getting any worse than it’s already become.
The No Surprises Act was supposed to end predatory billing. Unless policymakers close these loopholes, it risks becoming the opposite: a taxpayer-subsidized arbitrage scheme for global investors masquerading as healthcare providers.
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