AMA alerts officials of health plans' No Surprises Act abuse

Provider groups are adding fuel to the No Surprises Act fire, alerting administration officials to health plans that are undermining the law protecting patients from surprise medical bills.

The American Medical Association (AMA), along with 111 specialty societies and state medical associations, wrote a letter to the Secretaries of the Treasury, Health and Human Services, and Labor, calling for the administration to address enforcement gaps in the law's independent dispute resolution process (IDR).

Some health plans are inappropriately shifting costs to patients when IDR decisions are in physicians' favor, the letter warned. They are also exploiting technical guidance to reopen closed IDR cases to withhold payment from physicians, the groups added.

Additionally, providers have increasingly reported that health plans are failing to deliver payment within the statutory 30-day window after IDR decisions or are paying only a portion of the amount determined by IDR entities. In some cases, plans aren't paying physicians at all.

These gaps have led some health plans to circumvent the No Surprises Act "with harmful policies" that not only increase costs for patients, thereby violating the spirit of the law, but also "undercut independent physician practices, jeopardizing access to care in their communities," the letter stated.

A lack of transparency in the IDR process has also exacerbated issues that payers have complained about, including a flood of ineligible claims that have bogged down the process.

An October 2025 report from America's Health Insurance Plans (AHIP) and the Blue Cross Blue Shield Association found that almost 40% of disputes submitted to the IDR process were ineligible. Some payers have even pursued legal action against providers they say are abusing the process by filing ineligible claims for arbitration and extracting millions of dollars in wrongfully obtained IDR awards.

AMA and other provider groups explained that determining a claim's eligibility for the IDR process is a challenge for physicians. However, payers have plan information that allows them to identify eligibility more easily. Still, they fail to deliver that information and oftentimes participate in open negotiations or the IDR process.

Providers have been significantly more successful in the IDR process, but this is largely attributable to default decisions, according to a 2025 congressional report. Default decisions are issued when one party fails to participate or comply with procedural requirements, including paying the IDR entity's fee.

The administration should require open negotiations to go through the IDR portal and mandate that health plans use remittance advice remark codes and other relevant eligibility information at the initial payment or notice of denial, the groups suggested.

They also recommended that the administration require greater transparency in the calculations of the qualifying payment amount (QPA). QPAs aren't always accurate per the market rate for services, as the No Surprises Act intended, according to the letter.

AHIP also called for stronger enforcement of the No Surprises Act in an April 17 post. The organization wants greater transparency to "address the abuses of the No Surprises Act arbitration system by some private equity-backed providers and middlemen."

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.