January 23, 2026
Yesterday, senior executives from the nation’s largest health insurance companies testified before Congress in two high-profile hearings before the House Energy & Commerce Committee and the House Ways & Means Committee. Lawmakers sharply questioned health plan practices related to claim denials, downcoding, market consolidation, vertical integration, and implementation of the No Surprises Act (NSA)—many of the same issues EDPMA members face daily their practices.
EDPMA welcomes congressional oversight of health plan practices and appreciates the increased attention being paid to the real-world consequences of payer policies on patients, physicians, and emergency care delivery systems.
Congressional Scrutiny of Health Plan Practices
Throughout both hearings, members of Congress expressed bipartisan concern about insurer business practices that increase administrative burden, suppress reimbursement, and delay or deny appropriate payment for medically necessary care. Lawmakers raised pointed questions regarding:
- Excessive claim denials and post-payment recoupments.
- Systematic downcoding of emergency services.
- Algorithm-driven utilization management and claims review.
- Delays and procedural barriers in appeals and dispute resolution.
- Market power resulting from consolidation and vertical integration.
These lines of questioning directly reflect long-standing concerns raised by emergency physicians and reinforce the growing recognition on Capitol Hill that current payer practices undermine patient access, physician sustainability, and the stability of emergency care systems.
No Surprises Act (NSA) Implementation & Compliance
EDPMA remains focused on ensuring that NSA implementation aligns with congressional intent. Extensive EDPMA member surveys and data demonstrate widespread health plan non-compliance with the payment provisions of the NSA, including delayed payments, improper payment reductions, selective data submission, and procedural tactics within the Independent Dispute Resolution (IDR) process that distorts fair payment outcomes.
These practices undermine sustainability of physician practice and threaten patient access to emergency care, particularly in rural and underserved communities.
During the hearings, lawmakers openly questioned whether health plans are manipulating the Qualifying Payment Amount (QPA), selectively submitting data in the IDR process, and systematically delaying payment to gain negotiating leverage. Several members raised concerns that current NSA implementation favors insurer financial interests over fair payment and timely patient care, reinforcing the need for stronger statutory clarity and regulatory enforcement.
To address these systemic failures, EDPMA strongly supports passage of the bipartisan No Surprises Act Enforcement Act (H.R. 4710 in the House and S. 2420 in the Senate), which would increase health plan compliance with NSA payment requirements, improve IDR accountability, and enhance CMS enforcement authority to ensure timely, accurate, and transparent reimbursement for patient care.
Payer Market Consolidation & Vertical Integration
Several members of Congress raised concerns over increasing consolidation across the insurance and healthcare delivery markets. The growing concentration of payer power and vertical integration across insurance, pharmacy benefit management, provider services, and data platforms raises serious concerns about competition, pricing fairness, transparency, and patient access, particularly in emergency medicine.
Lawmakers highlighted concerns that vertically integrated insurer structures increasingly allow health plans to function simultaneously as payer, provider, data intermediary, and market competitor, raising serious questions about transparency, competition, and fair contracting practices. These dynamics disproportionately impact emergency medicine, where physicians must deliver care without regard to patient insurance coverage or network participation.
Negotiating Practices & Market Leverage
Lawmakers also questioned health plan negotiating tactics, highlighting the imbalance of power between large insurers and frontline healthcare providers. For emergency physicians and their practice groups, these practices directly affect reimbursement stability, workforce sustainability, and the ability to maintain full time emergency department coverage.
EDPMA Advocacy Actions
EDPMA continues to actively engage Congress, federal regulators, and coalition partners to:
- Enforce full compliance with the NSA by all parties.
- Strengthen IDR integrity and payment accountability.
- Advance passage of the No Surprises Act Enforcement Act (H.R. 4710 in the House and S. 2420 in the Senate) to enhance CMS enforcement authority.
- Combat improper payer data practices and benchmarking tactics.
- Address the downstream effects of consolidation and market dominance on emergency medicine.
These priorities will remain central to EDPMA’s advocacy strategy and federal health policy engagement.
The hearings mark an important inflection point in Congressional oversight of payer conduct. EDPMA is actively engaging policymakers, regulators, and coalition partners to ensure emergency medicine perspectives shape forthcoming legislative, regulatory, and oversight actions, particularly as Congress evaluates potential reforms to NSA implementation, IDR operations, and health plan accountability.
We will continue to monitor developments closely and provide updates as Congress advances legislative or oversight actions affecting emergency medicine and the business of emergency care. If you have questions or examples to share, please contact [email protected].