Physician Groups Want Better Enforcement of No Surprises Act

Dozens of physician groups, including the American Medical Association and the American College of Emergency Physicians, sent a letter to HHS and other federal agencies urging stronger enforcement of legislation meant to prevent “surprise billing.”

The No Surprises Act, signed into law in 2020 by President Donald Trump, was intended to protect patients from unexpected bills for care from out-of-network providers and to ensure fair contracts between health plans and physicians. It would do so by establishing an independent dispute resolution (IDR) process in which the insurer and the provider each come up with an offer and an independent third party would choose one of the two.

The physician groups say the process isn’t working as planned.

“Unfortunately, health plans are finding ways to circumvent the statute with harmful policies that shift costs onto patients and undercut independent physician practices, jeopardizing access to care in their communities,” argued the groups in their letter to the secretaries of HHS and the Treasury Department and the acting secretary of the Department of Labor.

The groups called for “increased enforcement” from the agencies and greater transparency around the IDR process.

They cited “problematic conduct,” such as payers losing IDR decisions then reprocessing claims, and forcing patients to pay higher cost-sharing amounts. Providers also claim that health plans are delaying payment, making only partial payments, or not paying at all. A survey of clinicians found that 22% of IDR awards owed to physicians and other providers in 2023 and 11% of awards in 2024 had not been paid.

Health plan representatives say they are following the law and making timely payments when disputes are properly adjudicated.

Matthew Fiedler, PhD, a senior fellow at the Brookings Institution in Washington, D.C., said that while he’s not certain that insurers always pay, he has yet to see data from any provider group that he would consider “reliable.”

“The IDR process has been going very well for providers,” he noted. They have been winning at high rates while offering high prices to arbiters. The resulting prices “greatly exceeded” payments for services prior to the No Surprises Act, he added.

The physician groups also called for greater transparency to address how qualified payment amounts (QPAs) are calculated. QPAs are supposed to reflect health plans’ median in-network rates, but providers question their accuracy.

According to L. Anthony “Tony” Cirillo, MD, president of the American College of Emergency Physicians, providers have filed thousands of complaints with the agencies over QPAs that are sometimes 60% of what Medicare reimburses for services.

“That’s really hard to believe,” Cirillo said, referring to median contracted rates being less than Medicare rates. “The math may be right, but we don’t know that anybody’s really asked them to show their homework.”

The physician groups also urged the federal agencies to mandate that the entire IDR process be conducted in the IDR portal, since that would increase transparency around submissions and help with eligibility issues.

AHIP (formerly America’s Health Insurance Plans) addressed the letter by pointing to recent investigations from the New York Times and STAT.

“Multiple investigations and expert analyses demonstrate that some providers along with IDR middlemen are relentlessly abusing a law intended to protect consumers from surprise bills, all to maximize their own profits at Americans’ expense,” said Chris Bond, a spokesperson for AHIP. “This persistent, provider-driven abuse of the No Surprises Act is driving billions of dollars in wasteful spending and raising healthcare costs for everyone.”

The Times investigation cites examples of physicians who used the law to secure extremely high reimbursements for common medical procedures — for example, ob/gyns winning awards that were 600 times higher than standard rates for placing intrauterine devices, and a $440,000 award to a surgeon for a breast reduction.

“Look, if there’s physicians or providers that are doing things incorrectly, and they are doing it repeatedly, that should be addressed by the agency,” Cirillo said.

The final rule governing the specific ways in which the No Surprises Act and the IDR process should be implemented has been pending for 2 years, Cirillo noted. Before anyone decides the IDR process doesn’t work, he said it’s important to have those rules in place, with all the players doing their respective parts.