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.