Unrealistically low initial payments, flawed Qualifying Payment Amounts (QPAs), and impractical contracting terms are among the heavy-handed tactics insurance companies use to push physicians to the independent dispute resolution (IDR) process as a last resort for fair payment, according to an analysis sent to Congress from ACEP, the American College of Radiology (ACR) and the American Society of Anesthesiologists (ASA).

Centers for Medicare & Medicaid Services data cited in the analysis validates the concerns physicians have voiced about insurance company behavior.

• In 2025, insurance companies failed to even participate in the IDR process and lost by default on 24.5 percent of IDR line items.
• Insurer offers of $1 or less occurred in 8.2 percent of line items, and nearly 40 percent of insurer offers were at or below the QPA excluding defaults.

Physician groups have prevailed in several lawsuits related to the No Surprises Act, with the courts rejecting insurance company practices.

The recent fifth circuit ruling affirms what ACEP, ACR and ASA have been telling Congress and regulators for years—the QPA is unreliable, fundamentally flawed, and used by insurers to game the system, drive down payments and narrow physician networks.

“Patients and physicians should not be blamed for problems created by insurance company business decisions,” said ASA President Patrick Giam, M.D., FASA. “When insurers choose to pass the cost of reasonable physician payments on to patients and employers rather than absorb those costs within their substantial revenues and profits, that is a choice to preserve their bottom line, not evidence that the No Surprises Act is failing. Patients deserve a system that protects their access to care and ensures the physicians who treat them are paid fairly.”

Congress should address true outliers without allowing insurers to use them as justification for weakening the dispute process or further squeezing community-based physician practices to boost their profits, the organizations said. Additionally, they are calling on Congress to strengthen enforcement of insurer obligations, scrutinize repeated defaults, extreme offers and QPA calculations, and preserve the balanced IDR framework established by the No Surprises Act.

“A fair and effective IDR process depends on accurate payment data, transparency, and accountability from all stakeholders,” said ACR CEO Dana H. Smetherman, M.D., MPH, MBA, FACR. “The process has been hampered by insurers refusing to negotiate fair rates, offering inadequate reimbursement, and artificially narrowing physician networks, rather than fully participating in good faith.”

“The No Surprises Act must be enforced, not undermined,” said ACEP President L. Anthony Cirillo, M.D., FACEP. “Insurers are ignoring the letter and spirit of the NSA. Congress should not look past insurers’ role in driving IDR claim volume and then failing to participate in the process. More can be done to strengthen NSA enforcement and hold insurers accountable when they routinely fail to follow the law.”