The No Surprises Act: Updates and compliance reminders

BY Matthew D. Earl, Esq. and Michael Alexander, Esq., Brown & Fortunato, P.C.

On July 1, 2025, CMS announced updates to the procedures to initiate the Independent Dispute Resolution (“IDR”) process available under the No Surprises Act (“NSA”). The IDR process provides an independent and binding arbitration to decide reimbursement disputes between providers and health plans for specified services. The updates are part of an ongoing effort to refine and improve the IDR process and represents the current administration’s first clear indication of a commitment to maintain and improve the IDR process. Providers should revisit the requirements of the NSA and its implementing regulations to ensure they comply with their obligations to patients, especially as members of Congress consider introducing new legislation expanding the enforcement authorities for providers and health plans that fail to comply with the NSA.

Refresher on the No Surprises Act

Now, more than three years after the NSA and its implementing regulations took effect, it continues to impact the health care landscape. The NSA aims to eliminate “surprise” medical bills which leave patients with staggering medical debt by prohibiting “balance billing” for specified services. But the NSA and its rules go beyond that simple prohibition and include mandatory patient notices, provision of good faith estimates of the cost of services, and procedures for dispute resolution interactions between providers and insurers.

Under the rules promulgated under the NSA, physicians, clinics, hospitals, emergency services providers (including air ambulances), are prohibited from doing the following:

1. Balance billing a patient who receives emergency services, even if the provider is out-of-network.
2. Balance billing a patient for non-emergency services provided by an out-of-network provider at an in-network facility.
3. Charging patients more than their in-network cost sharing amount in any of the situations described above.

Similarly, the NSA and its rules require providers to:

1. Provide a good faith estimate of expected charges to uninsured or self-pay patients before any services are rendered.
2. Advise patients of their rights under the NSA via posted notices and patient disclosures.
3. Coordinate with health plans to determine the correct in-network cost-sharing amount for services rendered by any out-of-network providers.
4. Engage in the IDR process if payment disputes arise.
5. Avoid collection efforts or credit reports for unpaid amounts which are under dispute until a final resolution is reached via the IDR process.

Overview of the IDR

When a provider renders services covered by the NSA, the provider and insurer must come to an agreement about the correct reimbursement rate. If they fail, the IDR process provides a backstop to efficiently determine the proper rate. The IDR continues to be a work in progress, but recent updates and reports demonstrate that the IDR process is improving.

Independent Dispute Resolution Procedures

When a patient receives emergency care from an out-of-network provider or receives services from an out-of-network provider at an in-network facility, the facility cannot bill the patient for any amount beyond the patient’s in-network cost-sharing amount. Instead, the provider must engage in the following process to obtain payment from the insurer.

Initial Payment/Denial: Submit a claim to the insurer. The insurer has 30 days to pay the provider or issue a denial. If the insurer denies the claim or pays the provider an amount that is too low, the provider may initiate the IDR process.

Open Negotiation: Following a denial or underpayment, the initiating party sends notice of open negotiation, causing the parties to enter a 30-day negotiation period wherein they must try to negotiate a payment amount. If negotiations fail, the process proceeds.

IDR Portal: Either party may initiate the IDR process within 4 days from the conclusion of the open negotiation period. Upon completion of the form, the initiating party must send the Notice of IDR Initiation to the non-initiating party. The parties must select a certified IDR entity, and each party submits a proposed payment. The arbitrator selects one of the two offers within 30 business days.

Updates to the Federal IDR Portal’s Forms

Parties initiating the IDR process through the federal portal will notice the following updates on the initial web form.

The initiation web form has been updated as follows:

• Selections for the health plan type have been adjusted to add clarity and assist with filtering out disputes that are not governed by the No Surprises Act.
• Additional fields and new validations are required for those subject to the 90-day cooling off period. The cooling off period prevents parties from re-filing the same dispute immediately after a decision has been made and ensures a period of stability and encourages parties to reach negotiated resolutions to disputes. The portal will now require the previous dispute’s reference number to verify a payment determination was issued at least 90 days prior to the new submission.
• The form will also require validation that the open negotiation period is complete.
• The form will prevent submission of any duplicate dispute line items that have the same claim number, DOS, and service code as previously submitted dispute line items.

Conclusion

Medical bills continue to be a primary area of focus for regulators, so providers should conduct a review to ensure they are fully in compliance with the NSA and other similar billing regulations. The NSA’s IDR process continues to improve and comprises a crucial tool that providers should consider utilizing to obtain fair reimbursement for the services they render.