ACEP Now

Correcting Course: Repairing Gaps in the No Surprises Act

When the No Surprises Act (NSA) went into effect in 2022, it had two main goals: to protect patients from unexpected medical bills and to create a fair way for health plans and medical providers to settle payment disputes. But more than three years later, the law’s impact tells a different story.

Flawed regulation and ineffective oversight have altered the balance between payers and providers, resulting in some insurers using this as leverage to shift payer dynamics and, in some cases, cancel long-standing provider contracts altogether. This leaves providers with a difficult choice: accept unreasonably low in-network rates or be forced out-of-network (OON) and rely heavily on the Independent Dispute Resolution (IDR) process to recoup some of their losses.

Emergency medicine providers are uniquely vulnerable to this imbalance, as they must treat all patients regardless of their insurance status or ability to pay — making them disproportionally affected by the soft regulations and the lack of enforcement that have greatly favored the insurance payers.

Compliance Gaps and Payment Delays Continue to Undermine Progress

Despite these challenges, the process has seen some improvements. According to an EDPMA member study, the timeline for adjudicating disputes has gone down from 211 days in 2023 to 164 days in 2024.¹ The volume of IDR determinations also surged by more than 500% in 2024, with providers maintaining a consistent win rate of more than 85%.²

However, there are still some elements that remain worryingly burdensome.

Even with clear rules requiring payment within 30 days of anIDR outcome, many health plans ignore the law and refuse to comply with IDR payment determinations. In 2024, non-compliance rose sharply to 69.2%, with morethan 8% of payments being paid incorrectly.³

These patterns have left providers to bear the financialburden, even in cases where disputes were resolved in their favor. Manypractices report that underpayments and delayed reimbursements are straining theiroperations and disrupting their ability to provide care. If insurers face noconsequences for ignoring IDR rulings, then they have little incentive tofollow the law or negotiate fair in-network agreements.

More troubling is that some practices report a pattern of health plans shifting costs back to the patient after IDR determinations don’t go their way.⁴ A flagrant violation of the law and a clear encroachment of the patient protections afforded under the NSA.

Fixing the System: What Needs to Change

Physician advocacy groups say that unless key flaws are addressed, providers will continue to face financial strain—and patients may eventually feel the impact, too. They outline several priorities for reforming current regulations and enforcement.    

1.    Correcting QPA calculations and transparency

‍Many providers contend that current rules surrounding the Qualifying PaymentAmount (QPA) make it easier for health plans to justify lower payments while making it harder for providers to contest them without going through IDR. Suggested fixes include:

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• Stricter rules on what can be included in QPA calculations (e.g., excluding “ghost rates” that don’t reflect actual contracted rates).

• Transparency around how insurers calculate the QPA.

• Enforced requirements to include the QPA in the initial payment.

• Regular audits of QPA data, as mandated by law.⁵

• QPA updates that account for inflation and the increasing cost of care.

2.    Improving the IDR process and data standards

‍Improving the IDR process itself is another priority. While providers currently win most of their cases, the process remains burdensome and inconsistent. Proposed improvements include:

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• Enforcing the use of standardized claim codes(RARC/CARC) so providers can easily identify which claims fall under the NSA.⁶

• Creating a more functional portal with the ability to document communication between insurers and providers to empower better enforcement.

• Increasing transparency by publishing more detailed IDR data to promote accountability and compliance.

3.    Enforcing rules that already exist

There is also widespread concern that current enforcement is too weak to deter bad behavior. Provider groups are urging regulators to:

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• Enforce statutory timelines for all IDR decisions and required payments.

• Monitor QPA methodologies to ensure they comply with the law.

• Resolve ongoing IDR backlogs that delay provider payments — even after favorable rulings.

• Respond promptly and consistently to complaints from both patients and providers.⁷

4.    Addressing bad-faith payment offers

Another growing concern is the submission of $0.00 payment offers from insurers during IDR disputes. These are not just lowball offers — they’re bad-faith tactics that undermine the integrity of the IDR process, violate statutory requirements for emergency care coverage, and contradict initial payment amounts.⁸

Provider Advocacy Matters

As the implementation of the No Surprises Act continues to evolve, provider voices remain critical to shaping its future. The opportunity to course — correct still exists, but doing so will require sustained advocacy to close enforcement gaps, fix flawed regulations, and ensure that payers are held accountable. By engaging with ACEP at both the state and national levels, providers can help push for the policy changes needed to restore balance and make the NSA work as intended.

Now is the time for providers to get involved. Whether it’s sharing data for member surveys, submitting feedback on your current IDR experiences, or engaging in grassroots advocacy — every action counts!

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Footnotes

1. In August 2024, EDPMA captured data from a member survey related to the IDR process of the NSA. The survey period included January 1 through June 30, 2024. In this survey, EDPMA members reported the average time from entering the portal to the IDR initiation. Their data found an average timeline of 164 days, a 22% improvement over the 211 days reported in EDPMA’s Deep Dive Survey in 2023.

2. Data from CMS’ quarterly “Supplemental Background on Federal IDR Public Use Files (PUF)” shows a prevailing rate above 85% for physician/hospitals/air ambulance providers in2024 (86% in Q1/Q2, 85% in Q3/Q4). The NSA requires the Department of Health and Human Services, Labor, and the Treasury (the Departments) to publish this information each calendar quarter. https://www.cms.gov/nosurprises/policies-and-resources/reports

3. The August 2024EDPMA Survey found a worsening pattern of non-compliance among health plans followingIDR payment determinations. Non-payments following an IDR determination jumped from 24% in 2023 to 69.2% in 2024. Incorrect payments also rose from 2.8% to8.3% during the same period.

4. The August 2024EDPMA Survey found that 2.5% (760 instances) of respondents received communication that changed the patient cost-sharing amount after the health plan did not prevail in IDR, despite the law making it clear that the amount owed by patients may never change as a result of the IDR process.

5. The No SurprisesAct provides for 2 types of health plan QPA audits: (1) shall conduct audits based on samples (per year up to 25 group health/individual governed by 42 U.S.Code § 300gg–111 and up to 25 group health plans as governed by 26 U.S. Code §9816); and (2) may conduct audits in response to complaints; to date,Departments have only announced complaint-based audits. Current reports present data from just CMS on enforcement, providing an incomplete picture of NoSurprises Act enforcement efforts

6. Physician advocates propose adopting policies included in the IDR Operations proposed rule. The proposed rule was released on October 27, 2023, and included requiring the use of existing RARC/CARC codes that communicate state vs.federal jurisdiction. According to CMS’ IDR PUF report data (as of May 28,2025), the primary cause of delays in processing disputes is the complexity of determining whether disputes are eligible for the FederalIDR process.

7. The Departments have created a few avenues to submit complaints and request assistance for non-compliance.However, since states, the Department of Labor, and the Department of Health and Human Services all share responsibility for enforcement, complaints do not consistently filter to the appropriate federal or state entity responsible for enforcement. Many providers receive no response or are asked to re-route their complaint months later.

8. Earlier this year,CMS paused the resolution of payment disputes where a health plan submits a“$0.00” offer in the IDR process. CMS has since instructed the IDREs to resume processing these disputes, but providers continue to urge CMS to explicitly direct IDR entities to treat a “$0.00” offer as a non-offer, which would result in a default win for the provider’s submitted amount.

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