AMA, dozens of physician groups: No Surprises Act needs enforcement

The American Medical Association along with 111 specialty societies and state medical association wrote (PDF) administration officials today to warn about health plans undermining the No Surprises Act and urge federal regulators to increase enforcement and transparency.

The No Surprises Act was designed to protect patients from surprise medical bills and promote fair contracting between payers and physicians by establishing a meaningful dispute process. Most independent physician practices hold little clout in contract negotiations with payers and are struggling for solvency under the weight of low reimbursement rates, increasing prior authorization requirements, and other draining health plan policies. Such challenges are partly responsible for private practices disappearing from the healthcare landscape.

"Unfortunately, health plans are finding ways to circumvent the statute with harmful policies that shift costs onto patients and undercut independent physician practices, jeopardizing access to care in their communities," the letter said.

The health organizations wrote the departments of Treasury, Health and Human Services, and Labor, all of which have an oversight role of the No Surprises Act. The letter asked the departments to use their enforcement authority to rein in several practices that violate the spirit-and the wording-of the law.

Specifically, the letter pointed to:

• Inappropriate Cost-Shifting onto Patients. Physicians have heard reports that payers are increasing patient cost-sharing amounts after an Independent Dispute Resolution (IDR) decision in the physicians' favor-a practice that is clearly in violation of the spirit, if not the language, of the No Surprises Act.
• Misusing Technical Guidance to Reopen Closed IDR Cases.Some health plans appear to be exploiting June 2025 technical guidance intended to allow IDR cases to be reopened in a narrow set of circumstances to reopen final IDR decisions as a way to withhold payment from physicians.
• Ineligible Claims in IDR. Eligibility is often challenging for physicians to determine, especially when it comes to determining the appropriate regulator. Payers possess plan information that makes them best suited to identify eligibility for the process yet often fail to provide necessary information to physicians.
• Lack of Transparency into Qualified Payment Amount Calculations. Physicians report that the calculations do not reflect the market rates for services, as intended under the law. More transparency in how rates are calculated should be required.
• Lack of Timely and Complete Payments. Health plans are failing to reconcile payment outside of the statutory 30-day window, paying only a portion of what they owe, or are not paying at all, often repeatedly and without consequence.

The letter acknowledges that implementing the No Suprises Act has been a complex undertaking.

"Fortunately, we believe that these issues can be addressed largely with increased enforcement and transparency," the letter said, adding, "We look forward to working with you to address these concerns to ensure that the NSA continues to protect patients from surprise medical bills while preserving the sustainability of independent physician practices."

The entire letter and supporting organizations can be found here (PDF).