Congress Targets Enforcement Gaps in the No Surprises Act
Key Takeaways
- Bipartisan legislation introduced in the House and Senate would strengthen enforcement of the No Surprises Act by authorizing penalties for missed payment deadlines after independent dispute resolution (IDR) decisions.
- Physician organizations argue some health plans are failing to comply with legally binding IDR determinations, creating financial strain for physician practices.
- The proposal reflects broader concerns about whether the No Surprises Act’s dispute resolution framework is functioning as Congress originally intended.
Congress is revisiting implementation of the No Surprises Act as lawmakers and physician organizations raise concerns that portions of the law’s payment dispute system are not being consistently enforced.
A bipartisan group of lawmakers recently introduced the No Surprises Act Enforcement Act (H.R. 4710/S. 2420), legislation designed to address alleged failures by health plans and other parties to comply with payment timelines following independent dispute resolution determinations.¹
The proposal would authorize penalties for parties that fail to comply with statutory payment requirements after a final and binding IDR decision and would provide federal regulators with more explicit enforcement authority.¹
Supporters describe the bill as a targeted effort to reinforce the original intent of the No Surprises Act, which Congress enacted in 2020 to protect patients from unexpected out-of-network medical bills while establishing a framework for resolving payment disputes between providers and insurers.
What the Bill Would Do
1. Authorize Penalties for Missed Payment Deadlines
Under the No Surprises Act, once an IDR entity issues a final determination, payment must generally be made within 30 days.
The proposed legislation would authorize penalties when parties fail to comply with those timelines following a binding IDR determination.¹
According to supporters of the legislation, the bill is intended to close what physician groups characterize as an enforcement gap within the current law.
The legislation would also clarify and strengthen federal regulators’ authority to enforce compliance with IDR decisions.¹
2. Reinforce the Binding Nature of IDR Decisions
A central argument from physician organizations is that the current statute already requires compliance.
In a May 11 letter to congressional sponsors, the American Medical Association (AMA), dozens of specialty societies, and state medical associations wrote that the No Surprises Act clearly states that IDR determinations “shall be binding upon the parties involved.”²
However, the groups argued that some physician practices continue to experience delayed payments, underpayments, or nonpayment even after prevailing in the IDR process.²
The organizations contend that without meaningful enforcement mechanisms, incentives to participate in the dispute resolution process in good faith may weaken.
3. Expand Regulatory Accountability
The legislation would also formalize federal enforcement authority over post-IDR payment compliance.
Supporters argue that additional oversight tools are necessary to ensure the dispute resolution process functions consistently and predictably for all parties.
The bill’s sponsors and supporting physician groups describe the proposal as restoring the balance Congress intended when the No Surprises Act was enacted.¹²
Why the Debate Matters
Financial Pressure on Physician Practices
Provider groups argue that delayed or missing payments can create operational and financial challenges, particularly for independent physician practices with limited administrative resources.
According to physician organizations, unresolved or delayed IDR payments may require practices to absorb unpaid costs, manage cash flow disruptions, and dedicate additional resources to pursuing payment compliance.¹,²
The May 11 coalition letter states that physician practices are “forced to absorb unpaid costs, finance delays, and shoulder uncertainty while insurers retain funds they are legally obligated to pay.”²
Ongoing Concerns About Compliance
The legislation follows continued concerns about implementation of the No Surprises Act’s dispute resolution process.
A 2024 survey cited by the AMA from the Emergency Department Practice Management Association found that 24% of responding emergency department practices reported that IDR awards were either unpaid or paid incorrectly within the required 30-business-day timeframe.¹
Physician organizations argue these issues undermine confidence in the system and increase administrative burden.
A Broader Conversation About No Surprises Act Implementation
The No Surprises Act was designed to remove patients from payment disputes over emergency and certain out-of-network care while establishing an arbitration-style process for providers and insurers to resolve reimbursement disagreements.
Since implementation began, however, the law has generated continued operational, regulatory, and legal challenges involving the following:
- IDR eligibility standards
- Payment methodology disputes
- Administrative backlog concerns
- Transparency and reporting issues
- Enforcement consistency
The May physician coalition letter notes that provider groups continue to support broader process improvements, including greater transparency, clearer remittance guidance, mandatory participation in open negotiations, and targeted audits to address recurring compliance issues.²
Competing Perspectives on Enforcement
Physician and Provider Perspective
Supporters of the legislation argue that enforcement authority is necessary to preserve the integrity of the IDR process.
Provider groups maintain that:
- Final determinations must be consistently enforced
- Delayed payments undermine the dispute resolution framework
- Additional accountability is necessary for all parties participating in the process
The coalition supporting the bill includes the AMA, more than 40 national medical specialty societies, and medical associations from states across the country.²
Payer and Implementation Perspective
Health plans and regulators have also faced challenges implementing the No Surprises Act, including rapidly increasing dispute volume and evolving federal guidance.
Federal agencies initially projected far fewer IDR disputes than have ultimately entered the system, contributing to administrative strain and operational complexity.
Some stakeholders have argued that broader reforms focused on transparency, eligibility screening, and process efficiency may also be necessary alongside enforcement measures.
Implications for Managed Care
For payers, providers, and health care organizations, the legislation could carry several implications:
- Increased enforcement exposure: Health plans may face additional penalties for delayed or incomplete compliance with IDR determinations.
- Operational adjustments: Organizations may need to strengthen post-IDR payment workflows and compliance monitoring.
- Regulatory oversight: Federal agencies could assume a more active enforcement role within the No Surprises Act framework.
- Provider relations: The legislation may intensify ongoing tensions around out-of-network reimbursement and arbitration processes.
The Bottom Line
The No Surprises Act Enforcement Act represents Congress’s latest effort to refine implementation of one of the most consequential health care billing laws enacted in recent years.
While the original No Surprises Act focused primarily on protecting patients from unexpected medical bills, the current debate centers increasingly on whether the law’s payment dispute framework is functioning as intended.
As lawmakers consider new enforcement mechanisms, the outcome could shape the next phase of No Surprises Act implementation for payers, providers, regulators, and patients alike.
References
- O’Reilly KB. Bipartisan bill would boost No Surprises Act enforcement. American Medical Association. Published May 21, 2026. Accessed May 22, 2026. https://www.ama-assn.org/health-care-advocacy/access-care/bipartisan-bill-would-boost-no-surprises-act-enforcement
- American Medical Association, American Society for Dermatologic Surgery, Association American Society for Gastrointestinal Endoscopy, et al. AMA sign-on re: NSA enforcement. Letter. May 11, 2026. https://searchlf.ama-assn.org/letter/documentDownload?uri=/unstructured/binary/letter/LETTERS/lfc.zip/2026-5-11-AMA-Sign-On-re-NSA-Enforcement.pdf
