For years, out-of-network reimbursement worked on payer terms. Rates were set, payments were issued, and providers had limited recourse.
The No Surprises Act changed that. Providers now have a direct, enforceable right to challenge underpayments through an independent process — one where they’re winning more than 85% of the time.
What is the No Surprises Act?
Implemented in January 2022, the NSA fundamentally reshaped the out-of-network (OON) reimbursement landscape – protecting patients from surprise medical bills for emergency services, certain non-emergent services performed at in-network facilities, and out-of-network air ambulance cases.
It also grants those providers the right to directly challenge health insurance companies’ underpayments through the Independent Dispute Resolution (IDR) process.
Arbitrators must consider several statutory factors when resolving payment disputes through IDR. Federal agencies, including HHS, CMS, and the Departments of Labor and Treasury, set the rules and govern the process — timelines, submissions, and oversight.
How Are Payment Disputes Resolved in IDR?
Certified IDR entities adjudicate disputes using baseball-style arbitration — meaning the arbiter must choose one party’s offer in full, with no splitting the difference. These entities oversee IDR procedural compliance, including submission requirements and timely filing deadlines.
Both sides are bound to the same rules and timeframes:
- After the insurers’ initial payment or denial, providers have 30 business days to open negotiation (ON).
- If no agreement is reached during ON, either party has 4 business days to initiate IDR. (providers are typically the initiating party).
- Once an IDR entity is selected and agreed upon, both parties have 10 business days to submit arbitration statements, briefs, and final offers.
- IDR entities have 30 business days to review submissions, request additional information, and issue a binding payment determination.
- The party whose offer is not selected must pay the award amount in full to the prevailing party within 30 calendar days.
- The losing party pays the award in full within 30 calendar days. The prevailing party’s IDR fee is refunded. (Both parties in the dispute are required to pay administrative fees).
This structured, impartial process allows OON providers to resolve payment disputes, replacing a system that historically allowed payers to exercise unilateral control over payments.
The QPA and IDR
One factor arbiters must weigh is the median in-network contracted rate, known as the Qualifying Payment Amount (QPA). The QPA is one factor arbiters must consider — not the controlling number. Courts have confirmed that arbiters must weigh all statutory factors equally. However, research suggests QPAs are frequently calculated below actual in-network contracted rates — meaning the benchmark payers lean on often understates what providers should be paid.
When Does the NSA Apply?
Not every claim qualifies. Here’s where the NSA applies and where it doesn’t, which depends on service type, facility status, and physician network status:
| Service Type | Facility | Physician | NSA Application |
|---|---|---|---|
| ER + Post Stabilization | Non-PAR (OON) | Non-PAR (OON) | Applicable |
| ER + Post Stabilization | PAR (INN) | Non-PAR (OON) | Applicable |
| Non-emergency/Elective | PAR (INN) | Non-PAR (OON) | Applicable unless valid N&C* |
| Non-emergency/Elective | Non-PAR (OON) | Non-PAR (OON) | Not Applicable |
*Notice and Consent
How Do IDR Outcomes Curb Bad Payer Behavior?
Providers prevail in over 85% of IDR cases (CMS 2025).
That number doesn’t happen accidentally. It happens when records are clean, offers are data-driven, and the argument is built around what arbiters are required to weigh.
The wins compound, too. Provider-specific awards and publicly reported IDR data create a track record — one that can anchor future in-network contract negotiations around real, market-driven rates rather than whatever the payer proposes.
The NSA’s IDR process is more than a tool to resolve real-time payment disputes.
It can also serve as leverage for providers to negotiate fairer in-network contracted rates.
How Are NSA IDR Awards Enforced?
Winning an IDR award is not the same as getting paid.
An enforcement process for payment of IDR awards exists under the implementing rules, but it is primarily an administrative function. When IDR entities issue binding payment determinations, payers are obligated to pay the award amount in full to the initiating party within 30 calendar days. If a payer fails to pay, the provider may file a complaint with CMS to initiate enforcement measures.
CMS has the authority to investigate complaints, require corrective action, and impose civil monetary penalties, though none have been applied to date.
Regrettably, enforcement has been slow and inconsistent. With violators facing little consequence, providers look elsewhere to secure payment — including the courts.
Federal courts remain split on whether the NSA gives providers a private right of action to compel payment. The Supreme Court declined to weigh in, leaving the Fifth Circuit’s ruling in place, which held that it does not. Some courts have been more open to provider claims, but outcomes vary based on jurisdiction.
That leaves Congress. The proposed NSA Enforcement Act imposes substantial monetary penalties and interest on payers who miss payment deadlines. If passed, it would create meaningful consequences for non-compliance for the first time.
Providers and legislators continue to work toward stronger enforcement mechanisms — because the IDR process itself is working, so compliance must follow.
Key Takeaways:
- The No Surprises Act replaced unilateral payer control over out-of-network payments with a structured, rules-based dispute resolution process.
- Certified IDR entities adjudicate disputes using baseball-style arbitration, with both sides bound by defined timelines and rules.
- Arbiters are required to weigh all statutory factors equally — the QPA is one input, not the controlling factor.
- Providers prevail 88% of the time in IDR. IDR awards also create a data track record that can strengthen future in-network contract negotiations.
- Enforcement remains the weakest link. CMS has authority to penalize non-compliant payers but has not applied penalties to date.
- Federal courts are split on whether providers can sue to compel payment. Outcomes vary by jurisdiction.
- The proposed NSA Enforcement Act would impose meaningful penalties on payers who miss payment deadlines — a development worth watching.
- Out-of-network providers have more leverage under the NSA than most realize. Capturing that leverage requires disciplined execution at every stage of the process.
See What IDR Can Do for Your Practice
The NSA created a substantial opportunity for out-of-network providers. IDR is working, win rates are high, and the legislative push for stronger enforcement is active. The providers capturing the most value are the ones treating IDR as a disciplined, ongoing operation rather than a one-and-done process.
Allia Group continues to monitor NSA legislative updates and emerging trends in IDR to shape our offerings and achieve maximum recovery for providers, including our Managed IDR Services. If you’re an out-of-network provider and would like to explore what IDR can recover for you, that’s a conversation worth having. Contact us for a complimentary consultation.
