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 physicians to settle payment disputes. 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 physicians, enabling some insurers using the NSA as leverage to shift reimbursement dynamics and, in some cases, cancel long-standing contracts altogether. Physicians face 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 physicians must treat all patients, regardless of their insurance status or ability to pay. This makes them disproportionally affected by the regulations and the lack of enforcement of the NSA as written that have greatly favored the insurance payers.

Undermining Progress

Despite challenges, the process has seen some improvements. According to an Emergency Department Practice Management Association (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 increased more than five-fold in 2024, with emergency physicians a consistent win rate of more than 85 percent.²

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

Even with clear rules requiring payment within 30 days of an IDR outcome, many health plans ignore the law and refuse to comply with IDR payment determinations. In 2024, non-compliance rose sharply to 69.2 percent, with more than 8 percent of payments being paid incorrectly.³ These patterns have left physicians and practices to bear the financial burden, even in cases where disputes were resolved in their favor.

Many practices report that delayed reimbursements and underpayments are straining operations and disrupting their ability to provide care. If insurers face no consequences for ignoring IDR rulings, then they have little incentive to follow the law or negotiate fair in-network agreements.

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