Emergency departments are the front door to our healthcare system, providing care to anyone, at any time. Ensuring their sustainability is critical to preserving access for all patients. The No Surprises Act (NSA), is a critical step to maintaining long-term emergency department access, while protecting patients from unexpected medical bills.
EDPMA supported the NSA’s patient protections from the beginning, and the data confirms those protections are effective. However, as implementation has evolved, gaps in enforcement, transparency, and insurer accountability are undermining the law’s intent. EDPMA, alongside other practice specialty groups, recently submitted a letter to the Departments of Treasury, Labor, and Health and Human Services outlining urgent concerns with the ongoing implementation of the NSA, while offering solutions to ensure the law functions as Congress intended.
EDPMA remains committed to the NSA. However, to ensure sustainable care delivery, compliance and regulatory enforcement are necessary.
Insurer Behavior Undermining the Law
Despite clear statutory requirements, health plans continue to fall short in their obligations under the NSA. Insurers frequently fail to engage meaningfully in the required open negotiation process. They typically respond to only half of negotiation attempts and rarely offer counterproposals.
This lack of good-faith engagement forces providers into the IDR process as a last resort to secure appropriate reimbursement. Data shows that clinicians use IDR sparingly, with only a fraction (~6%) of eligible claims proceeding to arbitration, reinforcing the process is functioning as intended and not being overused.
When disputes do reach IDR, providers prevail over 75% of the time, underscoring a consistent pattern of insurer underpayment.
Declining Reimbursement Threatens Emergency Care
Reimbursement for out-of-network care is declining at alarming rates. The letter highlights data showing a 47.7% drop in out-of-network emergency department reimbursement over recent years.
These reductions mirror EDPMA’s own findings, which demonstrate significant decreases in commercial reimbursement under the NSA and further compound the financial strain on emergency physician groups already experiencing cuts, inflationary pressures, and workforce shortages.
Sustained downward pressure on reimbursement for frontline clinicians threatens the viability of these essential services and presents untold potential harm to patients.
Flawed Payment Calculations are Driving Instability
A key driver of these issues is the continued reliance on flawed Qualified Payment Amounts (QPAs). As the coalition letter explains, many QPAs are as much as 300% lower than actual in-network rates, This creates a distorted in-network reference that disadvantages providers and misrepresents the true value of care. Despite being mandatory, inflationary updates are rarely applied to QPAs, further compounding the impact of their miscalculation.
Allowing insurers unchecked discretion in calculating QPAs, particularly in the absence of clear guidance, further exacerbates this imbalance and undermines the fair negotiation framework established under the law. Miscalculated QPAs fail to accurately reflect the true cost of care, and leave providers little choice but to pursue the IDR process to secure sustainable and appropriate reimbursement.
Administrative Burdens and Lack of Transparency
The letter underscores the significant administrative challenges providers face, particularly in determining IDR eligibility. In many cases, insurers fail to disclose basic and essential information about plan types used to determine whether a claim falls under federal or state dispute processes.
IDR is administratively complex and costly, requiring significant time and resources from, and creating an operational burden for, physician practices. Clinicians welcome the opportunity to avoid the IDR process altogether whenever possible. However, due to a lack of transparency and meaningful engagement from insurers, providers are often left with no alternative but to pursue IDR to resolve payment disputes and secure appropriate reimbursement.
This lack of transparency leads to unnecessary costs, delays, and inefficiencies that burden physician practices and the broader healthcare system.
A Path Forward: Enforcement and Accountability
EDPMA and its partners are calling on federal agencies to take decisive action to restore balance and ensure the NSA works as intended. Key recommendations include:
- Strengthening enforcement to hold insurers accountable for noncompliance and failure to engage in good-faith negotiations
- Improving transparency around plan information and payment methodologies
- Enhancing oversight of QPA calculations to ensure accuracy and fairness
- Supporting passage of the No Surprises Act Enforcement Act, which would establish meaningful penalties for insurers that fail to comply with IDR outcomes or statutory requirements
Emergency physicians stand ready every day to provide lifesaving care under any and all circumstances. To sustain this critical role, they must be supported by a fair, transparent, and enforceable payment system.
The NSA can and should protect patients while ensuring that providers receive fair and sustainable reimbursement. With targeted reforms and stronger enforcement, federal agencies can restore balance, reduce administrative burden, and safeguard access to high-quality emergency care for all Americans.