The federal No Surprises Act went into effect in 2022 with the goal of preventing surprise billing by implementing an independent dispute resolution process for payment disputes between payers and out-of-network providers.
In a Dec. 18 episode of Keeping up with the Radiologists, a podcast produced by Philadelphia-based Penn Radiology and AuntMinnie, Rich Heller, MD, associate chief medical officer of health policy and communications and national director of pediatric radiology at Radiology Partners discusses the NSA’s rollout and reception over the last several years.
Here are five takeaways from the episode:
1. CMS has reported both an influx of IDR initiation requests, a backlog of unresolved disputes and the rise of third-party entities working as arbitrators. According to an AuntMinnie, report from Dec. 2021, just before the program’s rollout, one unforeseen consequence of the IDR process was the termination of existing agreements with providers and lower physician payment rates.
“Their agenda was to disrupt the normal good-faith network contract negotiations that happen between a medical practice and an insurance company,” Dr. Heller said during the podcast. “The debate was never about [if] surprise medical billing [is] good or bad.” He added that this isn’t due to the language of the law itself, but rather the loopholes created by the law that insurance companies and third-party entities have exploited.
2. Becker’s reporting has reflected similar observations by physicians. For example, current law requires insurers to promptly pay physicians. If a physician or practice considers the payment to be inadequate, they can challenge it using the NSA’s IDR process. An independent arbiter then weighs in, and if they rule in favor of the physician, by law, the insurer must pay the physician or practice within 30 days.
However, Antonio Hernandez Conte, MD, the former president of the California Society of Anesthesiologists, told Becker’s that insurers still frequently delay the payment timeline.
“The No Surprises Act remains a continual burden for anesthesia practices as insurers delay payments for up to 90 or 120 days even if anesthesia groups are successful in the arbitration dispute resolution process,” he said.
3. Dr. Heller echoed this sentiment, adding that insurance companies use the shared savings incentives to profit off of reducing physician payments.
“”ou will very quickly see the math,” Dr. Heller said. “They have an incentive now, financially, to drive physicians out of network and then pay as little as possible so they can drive that shared savings fee. … The fees to process the claim were more than the actual care delivery itself,” he added, noting that third-party companies help insurance companies drive physician payment rates down.”
4. The American College of Radiology was one of several physician groups to express support for the No Surprises Enforcement Act in July 24. The legislation would impose a penalty three times the difference between the insurer’s initial payment and the IDR arbiter’s ruling per claim, which would also be subject to interest. The bill has not progressed since its introduction and committee referral.
5. Another significant issue within the IDR is the qualifying payment amount calculation, the term created by the statute to describe the median contracted rate. The American College of Radiologists said that the issue leaves providers with nowhere to go when payers present incorrect QPAs in an October 2025 letter.
6. Providers won between 83% and 88% of IDR cases in the first half of 2024, according to a June study published in Health Affairs. Providers often secured much higher amounts than insurers, with the median prevailing offer in some cases reaching 447% of the qualifying payment amount. The IDR process remains concentrated in Texas, Florida and Arizona, and among large provider groups, with third-party companies emerging to help smaller providers navigate the process.
