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.”