What Needs to Change

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

1. Correcting QPA calculations and transparency:

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

• 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. Although physicians currently win most of their cases, the process remains burdensome and inconsistent. Proposed improvements include:

• Enforcing the use of standardized claim codes so physicians and practices can easily identify claims that fall under the NSA.⁶
• Creating a more functional portal with the ability to document communication between insurers and physicians 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. Physician groups are urging regulators to:

• 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 payments—even after favorable rulings.
• Respond promptly and consistently to complaints from both patients and physicians.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

Advocacy Matters

As the implementation of the NSA continues to evolve, physician 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 regulatory flaws, and ensure that payers are held accountable. By engaging with ACEP at both the state and national levels, physicians can help push for the policy changes needed to restore balance and make the NSA work as intended.