A new RAND Corporation report, funded by the Emergency Medicine Policy Institute, confirms what many emergency physicians feel daily: payments are falling, administrative burdens are rising, and the No Surprises Act (NSA) has tilted the playing field toward insurers. This article explores the report’s findings on Independent Dispute Resolution (IDR), how insurers are using the NSA to cut payments, and what emergency physician leaders see as the path forward for fair reimbursement and sustainable emergency care.

A System Built on a Crumbling Business Model

Emergency physicians are accustomed to practicing in crisis mode. But the RAND report, “Strategies for Sustaining Emergency Care in the United States,” concludes that the system of emergency care itself is now in crisis, mainly because of how it is funded.

The data are stark. Between 2018 and 2022, real (inflation-adjusted) payments per emergency department (ED) visit fell by 3.8 percent for both Medicare and Medicaid, while commercial payments dropped by 10.9 percent for in-network visits, and by a staggering 47.7 percent for out-of-network visits. At the same time, roughly 20 percent of allowed amounts across all payers were never actually paid — about $5.9 billion annually in unpaid professional services for ED clinicians.

Facility and professional payments are also diverging. RAND’s national analysis found that from 2018 to 2022, ED facility-allowed amounts increased 18.65 percent in real terms, while professional-allowed amounts for emergency physicians fell 7.42 percent. Hospitals are increasingly paid more for keeping the doors open, while the clinicians providing the care are paid less.

For ACEP President L. Anthony Cirillo, MD, FACEP, the big-picture message from the RAND report comes down to three points. “The three things that everybody should know about the RAND report are, number one, they [report authors] basically said, ‘Wake up, America.’ The system of emergency care that we’re all going to need and rely on someday is failing.”

He added that the current financing model is fundamentally flawed. “The second lesson was that the current construct of financing emergency care, particularly on the physician side, is flawed and has been flawed since it was created. And it’s just that the system of payment is getting worse.”

Finally, federal and state policies have steadily expanded the responsibilities of emergency departments without expanding how those services are funded. The third message from Dr. Cirillo is that “We’ve been asked or told by the federal government to do many, many more things beyond what the original fee schedules were paying us to do, and we have to think outside of the traditional fee schedule box if we’re going to make the system sustainable.”

The No Surprises Act: Protection for Patients, Pressure on Physicians

The NSA was designed with a straightforward goal: protect patients from balance billing (also called “surprise billing”) in situations where they cannot choose their clinicians, particularly in emergencies. By that narrow metric, it has primarily worked. Patients are far less likely to receive large out-of-network emergency bills.

Dr. Abir

But the RAND report, along with interviews with emergency physician leaders, shows that the law has had profound, often unintended, downstream effects on physician reimbursement and contract negotiations.

Mahshid Abir, MD, MSc, the report’s lead author and an emergency physician and health policy expert, noted that the NSA created an Independent Dispute Resolution process to settle payment disputes between insurers and out-of-network physicians, but the combination of a low qualifying payment amount (QPA) from insurers, high IDR fees, complex rules, and lack of enforcement has shifted leverage decisively to payers.

From the physician side, Andrea Brault, MD, MMM, FACEP, CEDC, president and CEO of Brault Practice Solutions, said she believes that the QPA became a key inflection point. “Once payers had that tool, sanctified in rulemaking, it allowed them to artificially devalue emergency medicine services,” she explained. Insurers began sending letters telling long-standing in-network groups that their contracts would be canceled unless they accepted double-digit rate cuts.

Dr. Brault

Seth Bleier, MD, FACEP, vice president of finance for Wake Emergency Physicians PA, has watched those dynamics play out in real time. One insurer told his group it would need to accept a roughly 40 percent decrease in a long-standing commercial contract to remain in network. Groups that refused often found themselves pushed out of network, with initial payments far below prior rates — and a complicated, slow IDR process as the only avenue for relief.

Inside IDR: “Even When You Win, You Lose”

In theory, IDR under the NSA was supposed to be a quick, balanced way to resolve disputes when physicians believed commercial payments were too low. In practice, emergency physicians described a system that is expensive, slow, and easy for large payers to exploit.

Dr. Bleier

Dr. Bleier identified several pain points:

• High administrative burden and cost. For small and mid-sized independent groups, IDR fees and staff time can be prohibitive.
• Delays that crush cash flow. Many groups report an average six-month delay from date of service to payment — if payment comes at all.
• Non-compliance with arbiters’ decisions. Even when physicians “win” an IDR case, insurers sometimes pay partially, pay late, or do not pay the full awarded amount.

“The law created a process that, on paper, looks fair,” Dr. Bleier said. “But if there are no penalties for not following it, insurers can drag their feet indefinitely. That’s what we’re seeing.”

Dr. Brault agrees that implementation — not the core idea of the NSA — is the problem. Emergency physicians are winning a large majority of IDR disputes — about 80 to 85 percent by many accounts — because their offers more closely reflect the real cost of care. Yet insurers still rarely come back to the table for meaningful contract negotiations.

Dr. Cirillo framed it as “insurer math.” Because fewer than 10 percent of underpaid out-of-network claims go to IDR, even losing 85–90 percent of arbitrations still leaves insurers ahead financially. Underpaying the other 90 percent more than offsets arbitration losses.

Dr. Abir noted that current regulations also make it difficult for groups to batch related claims, adding cost and complexity. “[Physicians] need mechanisms to reduce the cost of IDR, speed up processing, including batching, and create real consequences when insurers don’t pay correctly or on time,” she said.

When Facility Fees Rise and Professional Fees Fall

The RAND analysis quantifies something emergency physicians have sensed for years: The financial benefits of emergency care are increasingly flowing to hospital facilities, not to the clinicians delivering the care.

From 2018 to 2022, commercial-facility-allowed amounts for ED services increased by nearly 19 percent, while professional-allowed amounts fell by more than 7 percent. Nationwide, insurance claims reviewed in the report showed that although facility charges have always exceeded professional fees, the gap widened substantially over the study period. Facility charges totaled $8.7 billion compared with $1.4 billion for emergency physician services — underscoring RAND’s finding that professional reimbursement is becoming a shrinking share of overall emergency care payments.

Dr. Abir described a “pretty overwhelming consensus” that emergency medicine has undersold its value. Communities and policymakers often see only the cost, not the broader benefits of emergency departments, from public health surveillance to disaster response. When an emergency department closes, nearby hospitals and communities feel the shock. Yet the clinicians who keep those doors open are seeing their professional payments erode over time.

Dr. Brault said she believes that the facility-professional gap reinforces the need to rethink advocacy. “We’ve tended to look at payment one claim at a time,” she says. “The RAND report pushes us to think more broadly about how society funds a system that everyone relies on, often unexpectedly.”

The Next Policy Battleground: NSA Enforcement

Given the misalignment between IDR’s intent and real-world performance, emergency medicine groups are pushing for stronger enforcement. A key example is H.R. 9572, the proposed No Surprises Act Enforcement Act, introduced by a bipartisan group of physicians in Congress in September 2024. The bill would require insurers that fail to pay IDR awards on time to pay interest and penalties on overdue amounts.

“Insurers consistently refuse to play by the rules, doing all they can to delay payments, or in some cases are outright failing to meet their obligations under current law. This bill will hold bad actors accountable and stop their dangerous, irresponsible abuse of the system,” said Alison Haddock, MD, FACEP, immediate past president of ACEP.

Organizations including the Emergency Department Practice Management Association (EDPMA) have also endorsed the measure, arguing that enforcement is critical to preserve independent emergency physician practices.

The RAND report also recommends:

• Securing dedicated funding for EMTALA-mandated care for uninsured and underinsured patients,
• Strengthening penalties for unlawful insurer behavior such as chronic underpayment, delays, and improper denials, and,
• Exploring state-level funding models, such as local or employer-based support, for surge capacity and public health preparedness.

Dr. Abir said she believes many promising solutions may emerge at the state level, where policymakers are closer to the real-world impact of ED instability.

Practical Steps for Groups Navigating NSA and IDR Now

While larger reforms play out, emergency physician groups need strategies to survive today’s environment. Interviewees highlighted several steps:

1. Know Your Data — Deeply: Dr. Bleier stressed the importance of robust revenue cycle reporting and analytics. Track denials, downcoding patterns, and partial payments by payer; identify where claims are being underpaid; and use public price-transparency data to understand what nearby hospitals are paid.
2. Take IDR Seriously — or Find a Partner: For groups pushed out of network or receiving low initial payments, IDR may be the only route back to fair reimbursement. Brault encourages groups to audit the impact of the NSA, assess which payers are most appropriate for IDR, and consider third-party assistance if in-house capacity is limited.
3. Strengthen Relationhips With Hospitals: Drs. Bleier and Brault noted that in some markets, payers negotiate directly with hospitals and offer improved facility terms if hospitals pressure physician groups to accept lower professional rates. That makes close alignment with the C-suite essential.
4. Engage in Advocacy — Local, State, and National: Dr. Abir emphasized pairing quantitative data from the RAND study with local ED stories. Dr. Cirillo noted that ACEP is pushing on multiple fronts, from Medicare cuts to longer-term physician fee schedule reform. Emergency physicians can get involved through state chapters, legislative meetings, and clear messaging about what the phrase “percent of Medicare” actually means in real dollars.

Reclaiming the Narrative: Emergency Care as A Public Good

Across interviews with physicians and RAND findings, a consistent theme emerged: Emergency medicine has been framed primarily as a cost center rather than a public good. Yet emergency departments are one of the few parts of the health care system that reliably say “yes” to everyone, 24/7/365, regardless of insurance or ability to pay. Emergency physicians are at the front line for pandemics, disasters, behavioral health crises, and routine emergencies alike.

Dr. Abir called emergency departments a “national treasure” whose value is underappreciated. Dr. Cirillo noted: “Times have never been easy, but we fought our way through, and we’ll continue to fight to make sure emergency medicine stays a viable practice.”

Where We Go from Here

For emergency physicians, the RAND report offers both validation and a roadmap. It quantifies what many have experienced anecdotally. Professional payments are falling while facility payments rise.

Insurers are using their leverage, and the NSA framework, to manipulate rates downward and delay or avoid payment.

The current funding model of emergency medicine is unsustainable without new approaches and real enforcement.

At the same time, the report highlights opportunities including strong IDR outcomes when claims are well-prepared, emerging bipartisan support for enforcement measures such as the No Surprises Act Enforcement Act exists and, new state-level models might be needed to fund surge capacity and public health roles that emergency departments already fulfill.

For ACEP members, the path forward involves both practice-level tactics and collective advocacy. It means knowing your numbers, engaging IDR strategically, strengthening hospital partnerships, and ensuring lawmakers understand that this is not just about physician reimbursement — it is about whether emergency care will be there the next time someone calls 911.

Editor’s note: ACEP Now reached out to UnitedHealthcare for comment on IDR implementation and NSA enforcement but did not receive a response in time for our publication deadline.

Leona Scott is a freelance writer based in Dallas.