The No Surprises Act was designed to protect patients from unexpected medical bills, but it has also created a complex administrative network that some leaders believe burdens independent practices.
Eric Haas, MD, chief medical officer of the American Academy of Value-Based Care, recently joined Becker’s to break down how the law has reshaped contract negotiations, what it is actually like to navigate billing disputes on the ground, and why good-faith negotiation requirements will matter only if regulators are willing to enforce them.
Editor’s note: These responses have been lightly edited for clarity and length.
Question: How has the No Surprises Act changed the way practices approach contract negotiations with insurers, and has it shifted the power dynamic at all?
Dr. Eric Haas: The NSA has been largely beneficial. It is patient-protective and helps make billing more predictable and transparent, which is always good. Patients and primary care full risk groups are also no longer at the mercy of higher charges from non-[participating] specialists.
There is also a noticeable change in the power dynamics of contract negotiations, with the balance shifting towards insurers. Before the NSA, some specialties had more leverage because insurers faced pressure from patients receiving large surprise bills. Now that patients are no longer part of the equation, there’s less practical leverage; insurers do not need to engage meaningfully before the IDR process.
The NSA has essentially created a new administrative reality: Payment disputes now require structured negotiation, documentation and often IDR.
Q: Have you or your group ever gone through the IDR process? What was your experience, and would these rule changes have made a difference?
EH: Being with PAR, I have not had direct experience with the IDR process.
However, on the ground, I have seen PPO-covered patients go into participating hospitals (which are PAR with health plans) only to find that the anesthesia physicians (non-PAR) or other specialists charge well above PAR rates. These then get passed on to patients and negatively impact risk primary care physicians too.
Those who have dealt with the IDR process describe it as being administratively heavy. A practice has to identify eligible claims, initiate open negotiation, track deadlines, submit documentation, pay fees and wait for determinations. The hardest part appears to be identifying eligible claims, getting complete information from the payer, tracking deadlines and managing the volume.
Will the newest rule changes make a difference? Yes, but only if properly enforced. For one, it will add the necessary protections to the problem I observed at participating hospitals. Better remittance information and a standardized open negotiation process should also reduce confusion and ineligible disputes.
Q: What’s one thing you wish policymakers understood about how billing disputes actually play out on the ground in practices?
EH: The most important thing for policymakers to understand is that billing disputes are not abstract payment disagreements, it is not just two parties negotiating on equal terms in a clean arbitration system. There are real-world implications for staffing, cash flow, time spent away from patient care, repeated follow-ups, and the viability of practices that provide essential access. You also have to factor in other variables such as a group’s infrastructure capabilities and network status.
A practice can be clinically excellent and still not have the infrastructure to dispute every inappropriate payment. When the process is too complex, the practical result is that some underpayments go unchallenged. This is especially important for independent groups, rural practices, hospital-based specialists, emergency physicians, anesthesiology, radiology, pathology and other groups that often cannot control whether they are seen as in network for every patient.
Q: The new rule requires good-faith negotiations before disputes enter arbitration. Do you think insurers will actually comply, and what should happen when they don’t?
EH: Some will, while others may comply technically without meaningful engagement. The concern is that an insurer can send the required information, wait out the negotiation period, and still force the practice into IDR. The newest rule change specifically responds to reports that parties were not meaningfully engaging during open negotiation and that open negotiation notices sometimes included large numbers of items that later turned out not to be eligible for IDR.
The good-faith negotiation requirement is a good idea in theory, but it needs practical enforcement to be effective. If a payer provides incomplete information, delays responses or uses the negotiation period as a formality, that should have ramifications. At minimum, there should be documentation standards, portal-level tracking, repeat-offender monitoring, and penalties or adverse procedural consequences when a party does not meaningfully participate.
As for those that do not comply, actionable steps should be taken:
- IDR entities should be able to consider failure to engage in open negotiation.
- Regulators should track payer patterns, not just individual disputes.
- Repeated incomplete remittance data or non-response should trigger enforcement review.
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