The No Surprises Act has made significant strides in protecting patients from large, unexpected medical bills. Unfortunately, the same cannot be said for the NSA’s promise to protect payments to physician practices.
It’s true that data from the Centers for Medicare & Medicaid Services points to an 85% success rate for providers in their independent dispute resolution cases against payers.
Victory doesn’t guarantee payment, however. It’s unfortunately all too common for arbitration awards to go unpaid, and for independent physicians to face stark decisions about their future while they wait for what they’re rightfully owed.
Individual lawsuits have proven ineffective at the state level in cutting down on delayed payments from insurers, and most federal courts have ruled out litigation to enforce awards. It’s clear that broader reforms will be necessary for the NSA’s impact to be truly felt across the industry.
After IDR losses, insurers hold the float instead of paying
Signed into law 2020 and taking effect in 2022, the NSA established the IDR process to handle situations in which providers and payers cannot agree to payment amounts following a 30-day open negotiation period. According to data released in July, providers won 85% of disputes that received payment determinations.
Determination is one step in the process, not the final one. Evidence is mounting that payments are coming in slowly and that delays are part of a pattern. For example, two providers have sued Anthem Blue Cross and Blue Shield in Colorado state court, claiming the insurer owes them a collective $2.1 million across 147 IDR determinations. When delayed payments stem from dozens of disputes, it’s a clear stalling tactic, not an isolated incident or administrative error.
This has become a pattern because insurers, especially publicly traded companies, have clear incentives to hold the float before they pay claims. To hold the float means to collect, hold onto and invest premium dollars and owed payments. Doing so for weeks or months at a time contributes to growth — Anthem’s parent company, Elevance Health, reported close to $200 billion in revenue in 2025, up nearly 13% from the prior year — at providers’ expense.
It doesn’t help that a 2025 Fifth Circuit ruling determined that providers cannot sue in federal court to obtain unpaid IDR awards. The U.S. Supreme Court has since declined to review the decision. As a result, enforcement of overdue IDR payments is largely up to the Department of Health and Human Services’ administrative complaint process, which, not surprisingly, is slower and less certain than litigation.
Independent physician practices feel the heat
Delayed IDR awards compound the financial strains independent physicians are already experiencing. As a poll from the Medical Group Management Association (MGMA) found, practices are three times as likely to say their operating margins are getting worse than they are to say things are getting better.
When practices are forced to wait for payments that a neutral arbitrator has ruled they are rightfully owed, they’re forced to pay out of their own pocket for payroll, facility costs and supplies. With 84% of practices reporting higher operating costs in 2026, according to a second MGMA poll, it’s a tough time to dip into the coffers to cover payments.
That has left many independent practices with little choice but to consider consolidation. Avalere Health and the Physicians Advocacy Institute reported that hospitals, health insurers and private equity firms acquired nearly 13,900 physician practices between 2024 and 2026. UnitedHealth’s Optum alone is now aligned with more than 135,000 physicians and advanced practice clinicians, making it the largest physician platform in the U.S. All told, more than 80% of physicians are now employed by hospitals, health systems or corporate entities. Data from the Government Accountability Office tells a similar story; GAO reported 47% of physicians were employed by hospitals, insurers or private equity-backed corporate entities as of 2024, up from less than 30% in 2012.
It’s a troubling trend, and allowing IDR payments to linger in limbo won’t help the cause.
The time for broad action is now
Expecting independent practices to file individual lawsuits to obtain IDR payments due to them is hardly in their best interests, especially when lawsuits have no guarantee of success. The real answer is systemic reform, and two recent developments offer positive signs of progress.
One is a Fifth Circuit decision that will require payers to recalculate qualifying payment amounts, which the court described as “artificially low” due to the inclusion of ghost rates for services providers do not actually deliver. Honest and transparent QPA calculations will reduce the number of payer-provider disputes that need to go through the IDR process in the first place.
The other is the NSA Enforcement Act, sponsored by U.S. Rep. Greg Murphy, M.D., R-N.C. The bill would create penalties when insurers fail to comply with the NSA’s timely payment requirements, closing the gap between prevailing in arbitration and getting paid.
The NSA is fulfilling its promise to patients by banning surprise bills, cost-sharing and out-of-network charges for in-network services. More must be done to get independent practices the money they’re owed for the services they provide under the provisions of the NSA. Forcing practices to do the legwork to get paid only makes it harder to stay in business at a time when the odds are already stacked against them.
The editorial staff had no role in this post's creation.