- Payers often underpay, miscalculate QPA, or skip required disclosures on NSA claims.
- Watch for red flags: missing QPA info, rising A/R days, or unusually low payments.
- Document everything, then escalate through open negotiation or federal IDR if needed.
- IDR lets a certified entity pick either offer after 30 days of failed negotiation.
- CMS finalized new IDR rules in May 2026, signaling stronger federal enforcement ahead.
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TL;DR
Payers don't always follow the No Surprises Act (NSA) when processing out-of-network claims, and that creates real problems for practices — underpayments, missing disclosures, denied claims, and slow reimbursement. Providers who know the common violations and red flags can catch issues early, dispute them through open negotiation or the federal IDR process, and protect their revenue.
The No Surprises Act, built on the framework of the Affordable Care Act, protects patients from unexpected medical bills for certain services from out of network. However, payers don’t always process claims in a way that aligns with the law’s requirements. For providers, these breakdowns can create significant administrative burden, delay reimbursement, and raise questions about whether plans are fully meeting their obligations under the Act otherwise known as the NSA.
In April 2026, the American Medical Association (AMA) and other physician groups urged HHS to strengthen enforcement. In May 2026, CMS finalized updated operations rules that streamline communication and clarify timelines — a sign that federal attention on payers is increasing. In this blog post, learn what to do when payers don’t follow the No Surprises Act, including dispute resolution options, payment challenges, and patient protections.
What the No Surprises Act requires health plans to do
Health plans and insurers have several key obligations when a claim involves services covered by the law. More specifically, they must:
| NSA requirement for health plans | What it means |
|---|---|
| Limit patient cost-sharing for covered services | For emergency services (including air ambulance services and others) and certain out-of-network services provided at in-network facilities, plans must treat the patient’s cost-sharing as if the care were in network. |
| Apply in-network cost-sharing rules | The patient’s deductible, copayment, and coinsurance must be calculated based on the in-network rate, and those amounts must count toward the patient’s in-network deductible and out-of-pocket maximum. |
| Issue an initial payment or denial notice | After receiving a clean claim for NSA-covered services, the insurance plan must either make initial payment amounts to the out-of-network provider or send a notice of denial of payment. |
| Disclose the qualifying payment amount (QPA) and other required information | With the initial payment or denial, the insurance plan must provide the QPA and other information needed for the provider to evaluate the payment amounts and initiate open negotiation if needed. |
| Participate in open negotiation | If the provider disputes the payment amount, the insurance plan must engage in the required 30-business-day open negotiation period. |
| Participate in the federal IDR process when applicable | If open negotiation regarding payment for the received care fails, the insurance plan must take part in the independent dispute resolution process, including submitting payment offers and supporting documentation on time. |
| Pay the final amount owed after IDR | If the IDR entity determines the out-of-network payment amount, the insurance plan must pay the required amount within the applicable timeframe. |
Note that the No Surprises Act does not apply to people with coverage through programs such as Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE because these programs already prohibit balance billing.
7 common ways payers fail to comply with the No Surprises Act
Given the complex legal requirements, it’s possible that payers don’t follow the No Surprises Act for every claim they process. Here are 7 common pitfalls.
1. Underpaying out-of-network claims
Payers don’t follow the No Surprises Act when they reimburse NSA-covered out-of-network services at amounts below the QPA — the median contracted rate payers use as a benchmark.
2. Incorrectly calculating the QPA
Payers don’t follow the No Surprises Act when they miscalculate the qualifying payment amount by using flawed methodology, incomplete contract data, or an inappropriate service code or geographic region.
3. Delaying initial payments
Payers don’t follow the No Surprises Act when they fail to issue a timely initial payment or notice of denial after receiving a clean claim for NSA-covered services.
4. Denying NSA-eligible claims
Payers don’t follow the No Surprises Act when they incorrectly deny claims that should qualify for NSA protections, such as certain emergency services or out-of-network care provided at an in-network hospital.
5. Applying incorrect cost-sharing amounts
Payers don’t follow the No Surprises Act when they calculate patient cost-sharing based on the billed charge or out-of-network rate rather than the in-network amount required under the NSA.
6. Ignoring federal notice requirements
Payers don’t follow the No Surprises Act when they fail to include required information — such as the QPA and disclosure language — when sending an initial payment or denial notice.
7. Creating barriers to the IDR process
Payers don’t follow the No Surprises Act when they make it harder for providers to pursue payment disputes. More specifically, they may delay responses, withhold necessary information, or fail to meaningfully engage in open negotiation or IDR.
How to identify a potential No Surprises Act violation
Providers can identify instances in which payers don’t follow the No Surprises Act by watching for payment, cost-sharing, and dispute-resolution red flags such as:
- Consistent absence of QPA or require NSA disclosures. The initial payment or denial notice consistently does not include critical information required by law.
- Increase in days in accounts receivable. The insurance plan does not issue an initial payment or denial on time after receiving a clean claim. Or it fails to pay the required amount after an IDR determination or delays payment beyond the required timeframe.
- Increase in denials. Emergency or facility-based claims are frequently denied as out of network even though they appear to fall under NSA protections.
- Unusually high patient cost-sharing amounts. For example, the patient’s coinsurance or deductible appears to be based on the billed charge or out-of-network rate instead of the in-network amount. This could cause a spike in unpaid patient balances.
- Unusually low initial payment. The payment seems low relative to the service, contract benchmarks, or the plan’s stated QPA.
Each of these red flags could suggest payers don't follow the No Surprises Act, meaning they did not process an NSA-covered claim correctly. For a deeper look at how payers try to get ahead of these disputes, check out this guide to how payers are getting ahead of claim denials.
What to do when payers don’t follow the No Surprises Act
If providers suspect payers don’t follow the No Surprises Act, they should document the problem, review the payer’s determination, request clarification or reconsideration, and escalate the dispute if needed.
Document the issue
Gather the remittance advice, EOB, QPA disclosure, denial reason, patient cost-sharing details, and all payer correspondence to create a clear record of the potential NSA violation.
Review the payer’s determination
Compare the payer’s payment, denial, or cost-sharing calculation against NSA requirements to identify whether the claim was processed incorrectly.
Request clarification or reconsideration
Contact the payer to ask for an explanation, correction, or reprocessing of the claim if required NSA information is missing or the determination appears inaccurate.
Escalate the dispute
If the issue is not resolved, pursue the appropriate next step—such as open negotiation, the federal IDR process, or a complaint to regulators—depending on the nature of the noncompliance. Since launching in April 2022, the federal IDR process has received more than 5 million disputes.
When providers should use the Independent Dispute Resolution process
Providers should use the federal IDR process when they:
- Receive an initial payment or notice of denial for an eligible out-of-network NSA claim
- Complete the required 30-business-day open negotiation period with the health plan
- Cannot agree on the payment amount
At this point, either party can initiate IDR, generally within four business days after open negotiation ends. Here’s an example:
An out-of-network anesthesiology group provides services to a patient undergoing surgery at an in-network hospital. The group health plan issues an initial payment that the group believes is far below the appropriate out-of-network amount for an NSA-covered claim. After completing the required 30-business-day open negotiation period without reaching agreement, the group may initiate the federal IDR process to challenge the payment amount.
How the federal Independent Dispute Resolutions process works
Here’s a step-by-step process that explains what providers can expect during the IDR process in health care:
| Step | What the provider does | What happens next |
|---|---|---|
| 1. Receive the payer’s initial payment or denial | Review the payment amount, denial reason, QPA disclosure, and patient cost-sharing details. | This tells you whether the claim may have been underpaid or mishandled under the NSA. |
| 2. Start open negotiation | If you disagree with the payment amount, initiate the required open negotiation process with the payer. | The provider and payer then have 30 business days to try to resolve the dispute. |
| 3. Decide whether to move to IDR | If open negotiation does not resolve the issue, determine whether the claim is eligible for the federal IDR process. | If it is, either party can initiate IDR after negotiation ends. |
| 4. Submit the dispute to IDR | File the dispute and submit supporting information showing why your payment amount is appropriate. | A certified IDR entity reviews both sides’ offers and supporting documentation. |
| 5. Receive the IDR decision | Wait for the IDR entity to choose either the provider’s offer or the payer’s offer. | The losing party generally pays the IDR entity fee, and the health plan must pay the final amount owed if additional reimbursement is due. |
How to strengthen your position during a payment dispute
To strengthen your position during a payment dispute, consider maintaining detailed documentation, understanding the QPA, tracking communication with the health plan, and monitoring deadlines carefully.
Maintain detailed documentation
Keep a complete record of the claim, remittance advice, QPA disclosure, clinical documentation, and payer correspondence so you can clearly support your position during negotiation or IDR.
Understand the QPA
Review the qualifying payment amount and related disclosures to identify whether the payer may have used an incorrect methodology or provided incomplete information.
Track communication with the health plan
Document every conversation, email, and notice exchanged with the payer to create a clear timeline of the dispute and any unresolved issues.
Monitor deadlines carefully
Track open negotiation, IDR, and payment deadlines closely to avoid losing your right to challenge the payer’s determination.
How No Surprises Act violations affect patients and independent practices
When payers don’t follow the No Surprises Act, these violations affect patients and independent practices significantly but in different ways.
| Impact on patients | Impact on independent practices |
|---|---|
| Higher out-of-pocket costs if cost-sharing is calculated incorrectly or patients are billed more than the in-network amount allowed under the NSA. | Delayed reimbursement and cash flow disruption when payers underpay claims, deny eligible services, or miss NSA payment timelines. |
| Confusion about what they actually owe when EOBs, billing statements, or payer communications do not clearly reflect NSA protections. | More administrative work for staff to review claims, investigate payer determinations, request reconsideration, and manage open negotiation or IDR. |
| Delays in resolving bills when payment disputes between providers and payers leave patient balances in limbo. | Higher operating costs due to the time and labor required to audit claims, gather documentation, and escalate disputes. |
| Financial stress and frustration if patients receive bills they should not owe or are asked to pay too much upfront. | Revenue leakage if NSA-related underpayments or payer errors go undetected and the practice does not recover the full amount owed. |
| Loss of trust in the provider or health plan when billing errors or an inaccurate good faith estimate create a poor patient financial experience. | Patient satisfaction challenges when patients call the practice about incorrect bills or cost-sharing amounts caused by payer processing issues. |
Fewer resources to advocate for themselves, since patients rarely have the time or expertise to challenge a payer's determination on their own. | Greater strain on small teams because independent practices often have fewer billing, compliance, and legal resources to manage complex payment disputes. |
Best practices for preventing No Surprises Act payment disputes
Following best practices helps independent providers prevent NSA payment disputes and promote consumer protections. Here’s how.
| Best practice | Why it matters | Action step |
|---|---|---|
| Identify NSA-covered claims early | Helps prevent billing and payment errors. | Flag common NSA-related services and claims for review. |
| Verify payer processing before billing the patient | Catches incorrect cost-sharing and payment issues early. | Review the remittance, EOB, and patient responsibility amount. |
| Audit QPA disclosures and initial payments | Helps spot underpayments and missing required information. | Check whether the payer included the QPA and paid the claim appropriately. |
| Standardize documentation and dispute workflows | Makes it easier to challenge payer errors quickly. | Keep claim records, notices, and payer communications organized in one place. Submitting clean claims through electronic claim submission from the start also reduces the chance of processing errors that lead to disputes. |
| Track payer trends and escalate repeat issues | Helps identify systemic problems and protect revenue. | Monitor underpayments, denials, and missing disclosures by payer and claim type. |
Frequently asked questions
- Delays in processing IDR claims
- Failing to apply in-network charges and cost-sharing for NSA-eligible services
- Lack of timely and complete payments
- Lack of transparency into QPA calculations
- Missing technical guidance
- CMS No Surprises Help Desk: 1-800-985-3059
- Online complaint portal: CMS No Surprises complaint form
Protect your revenue from NSA violations
Payers won't always get NSA claims right the first time, and independent practices can't afford to just absorb the difference. When you know the requirements, watch for red flags, and document every step of a dispute, you put yourself in a stronger position to get paid what you're owed.
The most successful practices don't wait for a payment problem to escalate. They build NSA compliance checks into their everyday billing workflow, backed by strong revenue cycle management, so underpayments and missing disclosures get caught before they turn into a drawn-out dispute.
Tebra's billing and payments tools, powered by AI and integrated with our EHR software, help you flag claim issues early, track payer trends, and keep your revenue cycle moving, so you can spend less time chasing payments and more time with patients.
Get a demo to see how Tebra can support your practice's billing and payments:
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