The No Surprises Act Explained: What Medical Providers Need to Know in 2025

If you’re an out-of-network provider and your revenue dropped 30-40% starting in 2022, you’re not alone. The No Surprises Act fundamentally changed how insurance companies pay out-of-network claims. Most practices still don’t understand how to navigate the new system. 

At Minevich Law Group, we’ve won federal arbitrations and recovered significant amounts for providers. Here’s what we see: insurance companies are systematically underpaying claims, betting that providers won’t know how to fight back or will miss critical deadlines.

What the No Surprises Act Actually Did to Your Revenue

The NSA took effect on January 1, 2022. The stated goal was protecting patients from surprise medical bills. It accomplished that. But it threw out-of-network providers under the bus in the process.

Here’s the fundamental change: patients can no longer be balance-billed for emergency services or when they receive care from out-of-network providers at in-network facilities. They only pay their usual in-network cost-sharing: copay, deductible, coinsurance. That’s it. The insurance company now pays you directly, and you cannot bill the patient for any remaining balance. If you disagree with what the insurance company pays you, your only recourse is arbitration.

Think about what this means. You’ve lost all your leverage. Before the NSA, insurance companies had to negotiate reasonable out-of-network rates because their members would receive massive bills if they didn’t. That pressure? Gone. Now insurers can pay you whatever they want, knowing you can’t go after the patient and that most providers won’t have the expertise or resources to challenge them through arbitration.

Who Gets Hit Hardest

The NSA applies when patients receive out-of-network care without their choice. This includes emergency care at any facility. It also covers services by out-of-network doctors at in-network hospitals or surgery centers. Air ambulance services are included, but ground ambulances are excluded.

The specialties getting crushed? The ones that have historically relied on out-of-network billing strategies. Surgeons are getting hit hard across multiple disciplines: plastic surgery, orthopedic surgery, vascular surgery, cardiac and thoracic surgery, neurosurgery, general surgery. But it’s not just surgeons. Anesthesiologists, radiologists, pathologists, emergency medicine physicians, assistant surgeons, hospitalists. They’re all seeing the same revenue collapse.

Why Your Payments Are So Low: The QPA Explained

Insurance companies now base their initial payments on something called the Qualified Payment Amount, or QPA. This is supposedly the median rate the insurer pays to in-network providers for the same service in the same geographic area.

Here’s the fundamental flaw: the insurance company calculates this number themselves. Think about that. The party obligated to pay you controls the benchmark for what’s considered fair reimbursement. The incentive to manipulate this calculation downward is built into the system, and we see it happen routinely.

Insurance companies combine rates from completely different specialties to artificially lower the median. They change geographic boundaries to include cheaper areas unrelated to your practice. They alter your billing codes to ones with lower reimbursement rates. Then, they calculate the QPA based on the code they picked, not the one you submitted.

The result? Initial payments that are sometimes 10-15% of your billed charges. I’ve personally reviewed cases where a provider submitted a $250,000 claim and received an initial payment between $1,000 and $ 2,000. That’s not a typo. One thousand dollars on a two-hundred-fifty-thousand-dollar claim.

And most providers are just accepting it.

Here’s What Nobody Tells You: Providers Are Winning

If you challenge these lowball payments through the federal arbitration process, you’re overwhelmingly likely to win. Federal Independent Dispute Resolution data shows providers win 77-85% of arbitration cases.

When providers win, the financial difference is dramatic. The median arbitration award is typically three to four times the initial QPA-based payment. For complex specialties like neurology, arbitration awards have exceeded ten times the QPA.

What does this tell you? Independent arbitrators who review all the evidence are consistently concluding that insurance companies underpay providers. The QPA numbers are artificially low. When someone examines the full picture, providers win.

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. And insurance companies are counting on exactly that.

The Federal Arbitration Process: Where Most Providers Lose Their Rights

If you want to challenge a low payment under the federal No Surprises Act, you need to follow a very specific process with unforgiving deadlines. Miss any one of these deadlines and you forfeit your rights permanently for that claim. No second chances.

The 30-Day Open Negotiation Period: Within 30 business days of receiving the initial payment or denial, either you or the insurance company must send written notice to the other party initiating an open negotiation period. This starts a 30-business-day window where you’re theoretically supposed to negotiate.

The 4-Day Deadline: After that 30-business-day negotiation period ends, you have exactly four business days to file for arbitration through the federal portal.

Miss this window by even one day and you cannot challenge that claim. Ever. The insurer’s lowball payment becomes final. You have no recourse. This deadline is unreasonably short, and this is where insurance companies make their money back. They know that practices without sophisticated tracking systems will miss this window. We’ve spoken to surgeons across many different specialties, such as GYN, plastic, orthopedic, spine, neurosurgery, IONM, pain management, and many more, who had viable claims worth hundreds of thousands of dollars that they forfeited simply because they didn’t realize the clock was ticking.

The 10-Day Submission Window: Once an arbitrator is assigned, both parties have 10 business days to submit their final payment offer and all supporting documentation. This is your only opportunity to make your case. The arbitrator will not ask for additional information later. Everything you want them to consider must be submitted in this window.

This isn’t a simple billing appeal where you state that you disagree with the payment. You need to build a legal case supported by evidence that addresses specific statutory factors. You need to present your credentials and experience, document the complexity of the patient’s case, provide market data showing what other insurers pay for similar services, demonstrate efforts you made to contract with this particular insurer.

Most billing companies have no idea how to do this effectively.

The Arbitrator’s Decision: The certified IDR entity has 30 business days to review the evidence and issue a written decision. This is baseball-style arbitration. The arbitrator must choose either your offer or the insurance company’s offer. They cannot split the difference. One side wins, the other loses.

The Collection Problem Nobody’s Talking About

Here’s something that should infuriate you: even when providers win arbitration, 52% of arbitration awards go unpaid.

You go through the entire process. You meet every deadline. You build a comprehensive case. The arbitrator rules in your favor and issues an award requiring the insurance company to pay you significantly more than their initial offer.

And then the insurer just doesn’t pay.

Why? Because the No Surprises Act doesn’t explicitly state that providers have the right to sue insurance companies in federal court to enforce arbitration awards. This legislative gap has created what lawyers call a “circuit split.” Different federal courts are reaching different conclusions about whether you can enforce these awards through litigation.

Some courts have found there’s an implied right of action. Without the ability to enforce awards in court, they reason, the entire arbitration process would be meaningless. Other courts, including the influential Fifth Circuit Court of Appeals, have ruled there is no private right of action under the NSA. According to these courts, your only option if an insurer refuses to pay is to file an administrative complaint with Health and Human Services and hope the agency eventually takes enforcement action.

Insurance companies are exploiting this uncertainty. They know that even if they lose in arbitration, there’s a decent chance they can avoid payment by simply refusing to comply and betting you won’t have the resources or expertise to pursue federal litigation.

This is why having an attorney, not just a billing company, is critical for NSA disputes. Only a licensed attorney can file a lawsuit in federal court to enforce an arbitration award. Billing companies hit a legal wall at this stage. They have no recourse when insurers refuse to pay.

Why Medical Billing Companies Can’t Handle This Work

Many providers assume their medical billing company can manage NSA disputes. This is a costly misunderstanding.

Billing companies cannot legally represent you in formal arbitration proceedings. That’s practicing law without a license. They cannot build a legal case with proper evidence and arguments addressing the statutory factors arbitrators must consider. They cannot sue to enforce an arbitration award in federal court.

The federal IDR process is a legal proceeding that results in a binding legal decision. The skills required are legal skills: evidence gathering, statutory interpretation, persuasive legal argumentation, and courtroom experience for enforcement. We constantly see providers who tried to have their billing company handle NSA disputes and either lost winnable cases or won arbitration, only to have no recourse when the insurer refused to pay.

What You Need to Win Arbitration

Winning an NSA arbitration case requires presenting evidence that addresses specific factors the arbitrator is legally required to consider.

Your training, experience, and qualifications matter significantly. Board certifications, specialized fellowships, years of experience, quality and outcome measurements, any unique qualifications or expertise. All of this helps establish that you’re not a commodity provider. Insurance companies argue that you should be paid the same as every other provider in your specialty regardless of your credentials. You need to prove otherwise.

The patient’s case complexity is often your strongest argument. Detailed documentation from the medical record showing patient acuity, comorbidities, the intensity of the service you provided, any factors that made the case more challenging than average. This evidence demonstrates that your case wasn’t a routine, straightforward procedure that deserves a routine payment.

Market data is critical. You need documentation of your efforts to contract with the insurer, evidence of what other insurers have paid you for similar services, data on contracted rates you’ve had with other plans in the past four years. This provides a concrete, market-based benchmark that directly contradicts the artificially low QPA.

Here’s what you cannot use: federal law explicitly prohibits arbitrators from considering your usual billed charges and any public payer rates from Medicare or Medicaid. These are off-limits. Your case must be built on other evidence.

The 10-day submission window is tight. You only get one chance. You need someone who knows exactly what arbitrators are looking for, how to present evidence persuasively, and how to frame legal arguments that directly address the statutory factors.

Special Advantages for New York and New Jersey Providers

New York’s Three-Year Window: New York has had surprise billing protections since 2015, predating the federal NSA. For fully insured New York health plans, state law governs the dispute resolution process, not federal law.

Here’s the most important advantage: you have up to three years to file for arbitration on eligible claims. Three years. Compare that to the federal system’s 30-day window followed by a four-day filing deadline.

This means claims from 2023 and 2024 may still be eligible for arbitration under New York law. Depending on your claim volume, this could represent tens of thousands or more in recoverable revenue.

You also don’t have to wait through the 30-day open negotiation period that the federal system requires. You can proceed directly to New York’s Independent Dispute Resolution process. And New York’s arbitration standard is generally more favorable to providers than the federal QPA-centric approach. New York arbitrators consider the 80th percentile of provider charges and whether there’s a “gross disparity” between your fee and fees paid to similar providers.

The catch? New York’s process only applies to fully insured plans (plans where an insurance company assumes the financial risk). For self-funded employer plans governed by ERISA, the federal NSA process applies instead. Determining which law governs a particular claim requires legal analysis. Get it wrong and you could file in the wrong forum and lose your rights entirely.

New Jersey’s Opt-In System: New Jersey enacted its own surprise billing law in 2018 that applies to fully insured plans. Uniquely, self-funded plans can voluntarily opt in to the state’s arbitration system. If a self-funded plan has opted in, you use New Jersey’s process instead of federal IDR. Determining which law applies to each disputed claim requires legal analysis.

What You Need to Do Right Now

Audit Your Recent Out-of-Network Claims: If you’re receiving payments at 10-30% of your billed charges, you’re leaving money on the table. Review your EOBs from the past year and identify any claim that lists a QPA amount for emergency care or inadvertent out-of-network services at in-network facilities.

Determining which claims qualify requires detailed legal analysis. You need to verify the plan type, confirm that state law rather than federal law governs the dispute, ensure you’re still within applicable deadlines, and assess whether the potential recovery justifies the arbitration costs. A free case evaluation can identify your highest-value claims before the window closes.

Stop Accepting Low Payments Without Legal Review: The math is straightforward. If you receive a $5,000 initial payment on a $50,000 claim, and the average arbitration award for providers who win is $15,000 to $20,000, you’re losing $10,000 to $15,000 every time you accept the lowball offer without challenging it.

Your billing company can’t represent you in arbitration. That would be practicing law without a license. They can’t build legal cases, interpret federal regulations, or sue to enforce awards when insurers don’t pay.

Before you accept any QPA-based payment that’s dramatically below your billed charges, get a legal opinion on whether arbitration is worth pursuing. The consultation costs you nothing. Accepting an underpayment without exploring your options could cost you tens of thousands of dollars per claim.

Partner with Experts Who Track Every Deadline: That four-business-day arbitration filing window is non-negotiable. Missing it means forfeiting your rights permanently for that claim. Building this infrastructure internally is expensive and complex. You need specialized software, trained staff, and attorneys for legal representation. Working with a law firm that already has this infrastructure eliminates the risk. We track every deadline, manage every filing, and ensure you never forfeit a claim due to missed timelines. This is what we do every day.

Ready to Recover What You’re Owed?

At Minevich Law Group, we’ve built our practice around this exact problem. We know the federal process inside and out, we understand New York and New Jersey state law, and we have the litigation experience to enforce awards when insurance companies refuse to pay. We’re not a billing company trying to expand into legal work. We’re attorneys who specialize in this area of law.

We offer free case evaluations. We’ll review your recent claims and calculate your potential recovery. No cost, no obligation.

For New York providers: If you have older underpaid claims, call us today. New York’s three-year arbitration window means claims you thought were too old to recover may still be recoverable, but that window is closing.

For providers nationwide: If you’re receiving payments at 10-20% of your billed charges, we can help. The federal arbitration process is available regardless of where you practice. We handle NSA disputes in all 50 states.

Contact Minevich Law Group today for your free case evaluation.

The statistics prove you’re overwhelmingly likely to win if you fight back. But only if you fight back correctly.