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

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.

Now is the time 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!

Dr. Brault is the immediate past Chair of the Emergency Department Practice Management Association. She is also current Chair of the ACEP Coding and Nomenclature Committee (Group 1) and a member of the ACEP Reimbursement Committee.

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, 2024, through June 30, 2024. In this survey, EDPMA members reported the average time from entering the portal to the IDR initiation. The average timeline was 164 days, a 22 percent improvement compared with 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 greater than 85 percent for physician/hospitals/air ambulance providers in 2024 (86 percent in Q1/Q2, 85 percent 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 2024 EDPMA Survey found a worsening pattern of non-compliance among health plans following IDR payment determinations. Non-payments after an IDR determination jumped from 24 percent in 2023 to 69.2 percent in 2024. Incorrect payments also rose from 2.8 percent to 8.3 percent during the same period.
4. The August 2024 EDPMA Survey found that 2.5 percent (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 NSA provides for two 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 NSA 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 versus 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 Federal IDR 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 physicians 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 physicians 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 physicians’ submitted amount.