No one should be afraid to get medical care because of the threat of a surprise bill. That’s why, when the No Surprises Act (NSA) took effect in 2022, it was a welcome development for patients and physicians alike.
This landmark law aims to protect patients from unexpected, often devastating out-of-network bills they might receive after receiving care in an emergency, or at an in-network hospital where not every physician or provider was on their insurance plan. The NSA not only protects patients but also promotes fair contracting incentives for physicians and insurers through an independent-dispute resolution (IDR) process.
But fast forward to today, and it’s clear that some health plans are undermining both the letter and the spirit of the NSA. Unless federal agencies step in with robust enforcement and transparency, the careful balance Congress created will unravel, putting patient access at risk and threatening the viability of independent physician practices. That is precisely the message (PDF) the AMA and 111 specialty societies and state medical associations are now sharing with federal officials.
I was honored to provide testimony on behalf of the AMA (PDF) at the first congressional hearing on NSA legislation seven years ago, when insurance-industry representatives also shared their views. After hearing our views and deliberating at length, Congress passed a sound law on surprise billing. To have insurers fail to follow its provisions is a source of immense frustration.
How insurers undermine the No Surprises Act
Disturbingly, some insurers are reprocessing claims after a physician prevails in IDR, increasing the patient’s cost-sharing amount leaving patients holding the bag. A 2024 study of emergency physicians (PDF) found that half had seen payers increase the cost-sharing amount after an IDR win. That must stop.
Timely payment following an IDR decision in the physician’s favor is another issue. Despite statutory requirements for insurers to pay within 30 days after an IDR decision, surveys reveal (PDF) widespread delays, partial payment, or no payment whatsoever. In 2024, nearly half of payments weren’t remitted in time, and a substantial percentage were either incomplete or never delivered.
Additionally, some insurers are exploiting technical guidance (PDF) intended for rare circumstances to broadly revisit previously settled payment determinations, using this as yet another reason to withhold payments to physicians—despite the guidance expressly stating that the 30-calendar-day requirement continues to apply “regardless of whether a request to reopen a closed dispute has been filed.”
Physicians, health professionals and health care organizations, meanwhile, spend countless hours and resources fighting over payment that should be final and timely. For independent physicians like me, completing the work required to successfully submit an IDR claim is a significant challenge in itself; to have an insurer ignore the law afterward is particularly exasperating.
Threat to independent physician practices
Many smaller physician practices cannot afford these payment delays or the repeat IDR fees. As a result, they disproportionately face barriers to participating in the IDR process (PDF) and are instead forced to accept the rates payers offer, even when they are well below market value or what is sustainable to run a practice. These actions can erode physicians’ ability to practice independently as well as patients’ access to care. Practices can’t stay open when reimbursement is unreliable—and patients can’t get care when their doctors are forced to shut their doors.
If these insurer tactics are allowed to continue, the results could be felt well beyond individual claims disputes. Many independent physician practices may not survive the continuous low reimbursement rates and administrative barriers to pursuing relief through the IDR process.
That means less competition, reduced choice for patients, and even higher premiums as market power further consolidates among large payers. Failing to enforce the NSA also means surprise bills and unpredictable costs may return, undermining public faith in both the law and the health system.
Realizing the goals of the No Surprises Act
The AMA is invested in the successful implementation of the NSA’s balanced framework and is committed to working with regulators and other stakeholders to address issues that may impede that success.
For example, health plans have expressed concern with the prevalence of ineligible claims entering the dispute process. It is often difficult for physician practices to determine if a claim is regulated under the NSA or a state statute, if it meets all the NSA’s eligibility requirements, etc. While plans hold the relevant eligibility information and have opportunities to challenge eligibility from the start, we support regulatory proposals to use remittance codes to clarify eligibility from claim inception and reduce ineligible claims in the system.
Similarly, as the volume of IDR claims is concerning to some, we are dismayed by data showing low participation rates by health plans in the entire negotiations and dispute process. For example, in the last quarter of 2024, 26% of disputes were resolved through a default decision and about 90 percent of default decisions were in favor of the physician or provider, showing low insurer engagement.
To increase engagement in the process and reduce reliance on IDR decisions, we have supported proposals to formalize the dispute system, including open negotiations, and increase participation by the health plans.
Why enforcement matters
Increased enforcement and transparency are the linchpins of meaningful NSA implementation. As outlined by the AMA and our partners in the Federation of Medicine, meaningful regulatory enforcement is needed to ensure that the NSA continues to protect patients from surprise bills and preserve the sustainability of independent physician practices.
The NSA is intended to safeguard patients and create a fair payment system for physicians. Insurers are subverting these protections by shifting costs, reopening closed cases and refusing payments. Regulators must now ensure that central tenets of the NSA including patient protections, fair and prompt payment, and good-faith negotiations are not optional, but standard procedure.
The NSA was put in place after a thorough assessment of surprise billing problems by Congress. But without strong federal enforcement, its effectiveness hangs in the balance. Now is the time for the departments of Health and Human Services, Labor and the Treasury to use their authority to realize the promise of the NSA for everyone who depends on America’s health care system.
