The No Surprises Act eliminated balance billing to protect patients, but it created a financial crisis for out-of-network providers. Insurance companies now control the payment benchmark through the Qualified Payment Amount (QPA), which they calculate themselves using their own median contracted rates.

The financial impact has been devastating. Providers across multiple specialties report revenue declines approaching 40% since the law took effect in 2022. Initial payments routinely arrive at 10-15% of billed charges, with some cases receiving even less. High-complexity surgical cases that previously generated substantial reimbursement now receive a fraction of their former payment levels.

Want evidence these payments are insufficient? Look at what happens in arbitration. When providers challenge these underpayments through the Federal Independent Dispute Resolution (IDR) process, they often achieve favorable outcomes. Federal data show that prevailing offers often exceed the QPA by meaningful amounts, commonly several multiples of the insurer’s figure. For high-acuity specialties such as neurosurgery and complex cardiac procedures, arbitrators have awarded as much as 10-12 times the QPA. This massive disparity suggests systematic underpayment by insurance companies, who now face reduced pressure to negotiate fairly since providers can no longer bill patients for the difference.

Why Emergency Providers Face Underpayment

The NSA hits hardest when providing emergency or involuntary out-of-network care for complex, high-charge cases where providers have no ability to select patients or obtain prior authorization. Yet reimbursement depends entirely on the Qualified Payment Amount (QPA), a benchmark calculated and controlled by the same insurance companies required to pay them.

The core problem is that insurance companies calculate the QPA using median contracted rates that fail to distinguish between routine scheduled procedures and life-threatening emergencies. They pool rates from different specialties within broad geographic areas, apply standardized formulas regardless of case complexity, and may not fully account for factors like emergency timing, surgical duration, and resource requirements. This methodology can produce artificially low benchmarks that get applied uniformly to everything from routine procedures to emergency aortic repairs and prolonged middle-of-the-night surgeries.

Federal agencies expected 17,000 to 22,000 annual IDR cases. Instead, providers have filed over 3.3 million disputes between April 2022 and May 2025. Monthly filings now exceed 200,000, showing providers nationwide are challenging low payments.

Revenue Impact by Surgical Specialty

If you’re an out-of-network surgeon in plastic surgery, neurosurgery, vascular, orthopedics, or cardiac surgery the data confirms what you’re experiencing. Severe underpayment is now the standard across surgical specialties. Research on emergency medicine claims found that before the NSA, mean out-of-network payments were 112% higher than the QPA. Self-funded plans paid 120% above QPA levels. Now those same providers receive a fraction of what they used to get paid. The drop hits hardest for complex emergency cases.

Reconstructive Plastic Surgery

Unlike cosmetic procedures that operate on a cash basis, reconstructive cases involving trauma, cancer reconstruction, or congenital deformities fall squarely within the NSA framework. This distinction is critical yet often overlooked.

Emergency hand trauma perfectly illustrates the problem. When a plastic surgeon gets called at 2 AM for a complex hand injury requiring microsurgical nerve and tendon repair, they have no ability to verify insurance or obtain prior authorization. The patient needs immediate specialized care to preserve function. These intricate multi-hour microsurgical procedures demand split-second decisions and the highest level of surgical expertise under extreme conditions. Insurance companies frequently dispute the CPT codes, attempting to downcode complex procedures to simpler ones with lower QPAs.

Neurosurgery

Neurosurgeons cannot delay emergency interventions for subdural hematomas, ruptured aneurysms, or acute spinal cord compression. These life-threatening conditions demand immediate surgical intervention regardless of insurance verification, often performed within minutes of patient arrival.

These procedures carry substantial charges due to their complexity and resource requirements. Yet initial insurance payments represent only a small fraction of what’s needed to maintain emergency neurosurgical coverage.

Cardiac and Thoracic Surgery

Cardiac surgeons performing emergency repairs for Type A aortic dissections face life-or-death scenarios where minutes matter. These emergency interventions require mobilizing teams of 8-10 specialists, cardiopulmonary bypass systems, and 6-10 hours of complex surgery, often performed in the middle of the night.

Yet insurance companies calculate QPAs for these procedures using their median contracted rates for the same CPT code. These calculations typically fail to account for the emergency nature of the case, time of surgery, or the complexity and resource requirements that distinguish life-threatening interventions from scheduled procedures. The result? Initial payments that represent a small fraction of the total charges.

Vascular Surgery

Ruptured abdominal aortic aneurysms and acute limb ischemia demand immediate intervention. These cases often require massive transfusion protocols, extended operating time, and complex surgical repairs performed under emergency conditions.

Acute limb ischemia cases demonstrate the critical importance of rapid intervention. Studies show amputation rates double from 6% at one hour to 13.4% at six hours, making every minute count. Yet the payment structure doesn’t reflect this urgency or the resources required for immediate response.

Orthopedic Surgery

Orthopedic trauma surgeons face a potential mismatch between case costs and payments. Complex revision procedures and trauma cases require expensive implants and specialized instrumentation. Emergency fracture repairs requiring immediate intervention face the same payment constraints as scheduled cases, despite vastly different resource requirements and timing demands.

The financial disconnect is particularly acute in orthopedics where a single implant can cost $10,000-$30,000. Initial QPA payments often fail to fully cover the hardware costs, leaving little to nothing for the surgical expertise, operating room time, and post-operative care required.

When initial payments fail to cover even the hardware costs, practices must choose between absorbing massive losses on emergency trauma cases or limiting their emergency coverage altogether. For orthopedic groups handling high volumes of trauma cases, this payment structure threatens not just profitability but the fundamental viability of maintaining emergency call coverage.

Intraoperative Neurophysiological Monitoring

IONM providers face a unique challenge under the No Surprises Act. These specialists prevent paralysis and neurological damage during complex spine, brain, and vascular surgeries by monitoring neural pathways in real-time. Despite the critical nature of their services and specialized training required, they are almost always excluded from insurance networks, triggering NSA protections on virtually every case.

Clinical studies demonstrate IONM’s effectiveness in detecting potential neurological injury, with documented reductions in surgical complications and mortality. Yet reimbursement for hours of continuous multimodality monitoring fails to reflect either the expertise required or the catastrophic outcomes prevented.

The Path to Fair Reimbursement

Whether you’re performing emergency neurosurgery at 3 AM, reconstructing trauma injuries, or providing critical intraoperative monitoring, the payment challenge is the same. Initial QPA-based reimbursements fail to reflect the complexity, urgency, and expertise your cases require. Yet federal arbitration data shows these underpayments can be successfully challenged when you know how to navigate the process and meet the strict deadlines.

Every underpaid emergency case and complex surgery represents money you can recover through arbitration. While federal data shows providers achieve favorable outcomes when they challenge insufficient payments, our firm has developed specialized expertise that consistently produces successful results in these disputes.

The problem? An estimated 90% of eligible claims never get challenged. Providers either don’t know they can fight back, don’t understand the process, or miss the strict deadlines.

Minevich Law Group specializes in No Surprises Act arbitration for surgical practices. We provide comprehensive analysis of your specialty’s recovery potential, identify and track every eligible claim before critical deadlines pass, develop specialty-specific arbitration strategies, and enforce awards through federal court when insurers refuse to pay.

Schedule your complimentary No Surprises Act revenue recovery assessment today. Call 516-202-2196 or schedule a free consultation to discover your specific recovery potential.