Two member surveys tracking actual payments find that Independent Dispute Resolution awards help sustain practices but fall short of pre-NSA payment once inflation is counted, contradicting claims that IDR is driving up costs.
WASHINGTON, D.C., NOVEMBER 9, 2026. The Emergency Department Practice Management Association (EDPMA) today released Following the Dollars: The No Surprises Act in Emergency Medicine, a two-part analysis of actual payment data from its members, who collectively serve approximately 60% of emergency department visits in the United States. As Congress, the Congressional Budget Office (CBO), and the Administration weigh whether the No Surprises Act (NSA) should be raising premiums, the findings show that, measured in real dollars, emergency physicians are paid less today than before the law took effect.
Public discussion of the NSA has focused on how often clinicians prevail in Independent Dispute Resolution (IDR) and on awards quoted as multiples of the Qualified Payment Amount (QPA). Neither measure shows what health plans actually paid. EDPMA’s surveys fill that gap by following payments through every phase of the NSA cycle: the pre-NSA contracted rate, the initial out-of-network payment, and the final IDR outcome.
Part I: The Level 4 Visit tracked one of the most frequent emergency visit codes (CPT 99284) across 873,900 commercial visits in 47 states. Part II: Cash Per Visit widened the lens to every emergency visit level, measuring practices’ average commercial cash per visit before and after the NSA. Key findings include:
- Initial payments were cut nearly in half. After the NSA, the average initial out-of-network payment for a Level 4 visit fell 49.7%, from $567.26 to $285.21, consistent with the 47.7% reduction found in a 2025 RAND Corporation study.
- IDR awards do not keep pace with inflation. The average Level 4 IDR award of $649.06 was 98% of the inflation-adjusted pre-NSA rate of $660.68.
- Across all visits, practices are paid less than before the NSA. Average commercial cash per visit fell 6.0% after the NSA, from $421.51 to $396.10. Even with the assumption that every IDR award was actually paid by the health plan, average cash per visit reached only $417.52, below the pre-NSA level and 15.0% below the inflation-adjusted level of $490.93.
- Many awards remain unpaid. $78.3 million in IDR awards owed to survey respondents was still unpaid as of August 2026, including $22.2 million more than a year old.
- Most underpaid claims never reach IDR. Only 26% of out-of-network visits from 2022 to 2025 were submitted to IDR. The impact of underpayment on the large majority of claims (74%) that never go to IDR overrides gains in IDR.
These results do not account for IDR fees or other internal costs, which make current payment rates even less sustainable than the data show.
“The data are clear: IDR is not a windfall for emergency medicine,” said EDPMA Chair, William Freudenthal, MD, FACEP. “Plans cut initial payments nearly in half, and even after arbitration, emergency physicians are paid less than before the No Surprises Act once inflation is counted. Policymakers deserve an accurate view of the NSA’s impact, and that means looking at actual dollars, not win rates.”
“These findings raise serious questions about what is actually driving premium increases,” said Randy Pilgrim, MD, FACEP, Chair of EDPMA’s Federal Health Policy Committee. “Emergency physicians treat every patient who comes through the door, regardless of insurance or ability to pay. Our practices need sustainable rates of payment to keep providing 24/7 access to care.”
EDPMA urges policymakers to measure the NSA in dollars rather than win rates, to account for underpayments on claims that never go through IDR, to enforce timely payment of IDR awards, and to let IDR work as Congress wrote it, with no single factor, including the QPA, presumed to be primary. Fair initial out-of-network payments would mean fewer disputes, lower administrative costs, and more in-network agreements. EDPMA will brief Congress and CBO on its aggregate survey findings.
Both reports are available at edpma.org [Part I, Part II].
Media Contact: Matthew Clark, Executive Director, matt@edpma.org, Tel: +1.202.204.8400