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New report shows NSA is working. So, why are payers, providers still mad?

A new report suggests greater in-network participation since the No Surprises Act, but more work needs to be done to iron out the law's wrinkles for major stakeholders.

Jacqueline LaPointe
By
Published: 25 Feb 2026

A recent report published by the Government Accountability Office (GAO) indicated greater provider participation in health plan networks following implementation of the No Surprises Act (NSA), suggesting fewer surprise medical bills for patients.

In 2022, the NSA generally prohibited surprise medical billing, or balance billing, for certain services in key medical situations, including when patients go to the emergency department, receive care from out-of-network providers in an in-network facility, and receive air ambulance services rendered by out-of-network providers.

The law shields patients from these unexpected -- and typically, high -- medical bills, instead putting the responsibility on providers and payers to agree on a price for the care through arbitration.

The GAO report analyzed how NSA implementation has impacted network participation and payments to specialties most likely to be affected by the law: emergency medicine, radiology, anesthesiology and air ambulances. Researchers used the percentage of in-network claims billed as a proxy for changes to network participation.

The report showed that the percentage of in-network claims increased for three of the four specialties after NSA took effect -- the exception being radiology, where the in-network claim rate remained high and largely unchanged from 2019 through 2023.

For emergency medicine and anesthesiology, though, the in-network claim rate had declined prior to NSA implementation and increased after it went into effect. These two specialties are among the top for balance billing.

Rep. Jason Smith (R-Mo.) and the Chair of the House Committee on Ways and Means said that the "GAO report confirms what we hoped to see: the No Surprises Act is protecting patients and encouraging more care to be delivered in-network, which means fewer surprise bills and more certainty for families."

Payers, providers spar over the IDR process

Payers and providers have engaged in an ongoing battle to improve the independent dispute resolution (IRD) process under the NSA. The IDR process is a baseball-style arbitration system for payers and providers to settle payment disputes arising from surprise medical bills.

However, the IDR process, as it currently stands, has left a bad taste for both stakeholders despite overwhelming support for the NSA's primary purpose of protecting patients from surprise medical bills. Just this week, a group of more than three dozen payers, employers and patient advocacy groups called on the Trump administration to interfere with the process amid rising concerns about IDR misuse and its impact on healthcare costs.

Recent data from a coalition of national payers revealed that nearly 40% of payment disputes submitted were ineligible for the IDR process. Still, many of the disputes advanced through the process.

"The IDR process must serve as a backstop -- not a pricing mechanism or profit-seeking tool. Without necessary actions, misuse of the system will continue to raise costs for patients and undermine the affordability and stability of employer-sponsored coverage," the groups, including Elevance Health, Business Group on Health and Blue Shield of California, said in the Feb. 24 letter to the Trump administration.

Providers also heavily criticize the IDR process due to the significant administrative burden of submitting and supporting claims, delays in payments from payers and a bias toward payers regarding the qualifying payment amount (QPA), which certified IDR entities use to calculate a final determination. The Texas Medical Association notably went to court several times over the IDR process, with a case specifically arguing regulations overinflated the QPA's weight in final determinations.

Despite concerns on both sides, the IDR process remains popular. CMS recently reported that payers and providers submitted almost 1.2 million disputes in the first half of 2025, almost 40% more than in the second half of 2024. Certified IDR entities continue to face a backlog of cases, even though CMS says they are managing it.

NSA implementation continues, changes to come

Since the IDR process went into effect in 2022, payers and providers have encountered problems and called for change. However, they have been left waiting for meaningful improvements to the process.

The proposed rule published by the Biden administration in November 2023 addressed some challenges by seeking to allow broader batching of claims, a new eligibility determination review process and updated open negotiation requirements. However, HHS and related departments have yet to finalize the rule despite it being an agenda item on the first Unified Agenda of President Donald Trump's second term.

The rule's finalization may have been delayed by a historic government shutdown, but even if it is finalized early this year, policies could take up to 180 days from the rule's publication to take effect, according to Jeffrey Davis, senior director at McDermott+.

The Departments will also likely need to release guidance and FAQs following the final rule to support the rule's policies, Davis continued.

Smith also called on lawmakers to continue implementing the NSA, especially in light of the GAO's report.

Many NSA provisions have yet to go into effect, including advanced explanation of benefits requirements, provider directory standards and health plan transparency on insurance identification cards. Smith also urged action on IDR process improvements, particularly around eligibility and QPA transparency.

"The report underscores further improvements for patients are possible if the law is fully carried out as Congress wrote it, which the Biden Administration’s regulatory structure failed to provide," Smith stated. "This will ensure Americans see the full affordability and transparency benefits the NSA promised."

Jacqueline LaPointe is a graduate of Brandeis University and King's College London. She has been writing about healthcare finance and revenue cycle management since 2016.

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