Physicians Push Feds to Enforce NSA Payment Determinations
By Alisa Pierce

The Texas Medical Association, alongside the nation’s physicians, is pushing for better enforcement of payment protections under the No Surprises Act (NSA), calling on federal regulators and lawmakers to take stronger action to prevent health plan practices that place financial burden on physicians and harm patients’ access to care.

The renewed effort comes amid federal moves addressing lingering challenges under the NSA, including recent rulemaking with input from TMA and proposed legislation to penalize insurers that fail to comply with payment provisions.

TMA co-signed two American Medical Association letters sent April 27 and May 11, asserting that when the law’s independent dispute resolution (IDR) process between health plans and physicians award in the latter’s favor, some health plans are not paying within the statutory 30-day timeframe following an IDR determination, pay only a portion of what they owe, or do not pay at all.

One letter also notes reports that when an IDR determination awards a higher payment to physicians than an insurer initially offered, some health plans recalculate claims to place additional cost-sharing obligations onto patients, medicine says.  

Fort Worth radiologist Tilden Childs III, MD, says these practices discourage patients from seeking care while forcing physicians to absorb unpaid costs they are legally owed, which negatively impact physician practice viability and could force some practices to stop offering certain services, reduce hours, or close locations.

Dr. Childs is a member of Radiology Associates of North Texas, which despite prevailing in approximately 95% of federal IDR disputes, says more than $3.5 million in awarded balances remains unpaid by a Texas health plan.

“If physicians can't provide care, patients are going to suffer,” said the past chair of TMA’s Council on Legislation and current board trustee. “TMA’s work here is to ensure physicians can continue to provide the quality of care that patients deserve.”

Organized medicine therefore calls on the federal regulators to step up their enforcement with improvements such as:

• Revising technical guidance to prohibit insurers from reopening settled IDR determinations without sufficient cause;
• Heightening transparency in how qualifying payment amounts are calculated and exerting oversight to ensure rate calculations abide by statutory requirements; and
• Imposing penalties on insurers that fail to apply in-network benefits to care protected by the NSA.

Organized medicine is also backing the proposed NSA Enforcement Act, which, if approved, would help hold insurers accountable for violating NSA provisions. Although the NSA gave the Centers for Medicare & Medicaid Services the ability to oversee implementation of the IDR process, the legislation would help to hold health plans accountable for not complying with IDR payment determinations.

 If approved, the act would:

• Impose congressional reporting requirements regarding insurer violations;
• Mandate insurers notify the U.S. Department of Health and Human Services (HHS) of required payments; and
• Authorize penalties on any party that does not adhere to IDR payment timelines following a final, binding IDR determination.

“What we need is basically to level the playing field so that the payers and physicians are equally exposed to penalties if they don't follow the final IDR resolution process,” Dr. Childs said.

TMA also is monitoring new federal rules finalized by HHS that make several operational changes related to the federal IDR process. While some remaining guidance is pending, the final rules include language to address several concerns TMA raised in 2024. Those include a reduced administrative fee, expanded batching options, and a requirement for plans to use claim adjustment reason codes and remittance advice remark codes to help communicate whether a claim is eligible for federal IDR.

Meanwhile, TMA is seeking to build on a string of successful NSA court victories with a final pending federal lawsuit after the U.S. Court of Appeals for the Fifth Circuit granted TMA a rehearing, which was held in September 2025.

For more information about the No Surprises Act and TMA’s litigation, check out TMA’s Surprise Medical Bills webpage.