Allegro

The surprise in the No Surprises Act

Volume 126, No. 7July, 2026

Martha Hyde

This article is part of Allegro’s ongoing series on healthcare and how it affects our members.

The “No Surprises Act” was proposed in 2019, was signed into law on December 27, 2020 and became effective on January 1, 2022.

It was intended to prevent patients from receiving unexpected “balance” bills from providers outside their insurance networks after receiving services from those providers either without knowing they were out of network or because there was a medical emergency and/or an airlift. It had broad, bipartisan support and it has succeeded in protecting patients from these “surprise” bills.

The act contains a provision which allows providers who are no longer allowed to seek extra payments from patients to extract the payments from the insurance companies. There is a required 30-day period of negotiating over a qualified payment amount (QPA) which is the median amount paid for the service by plans in that market. After 30 days either party can seek an Independent Dispute Resolution (IDR) which is an arbitrator who decides the amount owed. This has given rise to Independent Review Resolutions Entities (IDREs) which supply the arbitrators who decide the amounts.

Because of the way arbitrations are structured, the amounts awarded to providers have ballooned in a way no one expected. The IDREs receive fees for the rulings and if the rulings are favorable to the providers they will bring ever more cases to the IDREs which gives the IDREs an incentive to award high amounts. A recent NY Times article reported on a plastic surgeon who does breast reductions which are advertised at $15,000 to $20,000. This surgeon has been awarded amounts up to $440,000 for the procedure. There is also a No Surprises Enforcement Act in the pipeline which would force insurers to pay awarded amounts within 30 days and would also strip the QPA of the assumption that it is fair.

Health insurance companies are not popular with providers, Congress or the general public so there is little sympathy for them when they pay out inflated amounts for services. Unfortunately for us patients, if their costs go up so do ours because they will pass the costs on in higher premiums and copays.

Congress and the enforcing agencies also rarely make the distinction between a for-profit insurance company and a self insured multiemployer health plan. Health plans are getting hit with these high IDR awards so the National Coordinating Committee of Multiemployer Plans (NCCMP) has taken up the cause, writing to the government to point out that the burden of these costs will fall right back onto the people who are supposed to be protected by the No Surprises Act.

However, the agencies responsible for enforcing the law are the Department of Health and Human Services (Robert F Kennedy Jr.). the Department of Treasury (Scott Bessent) and the Department of Labor (Keith Sonderling). Given the actions taken by these three on other matters, the appeal may fall on deaf ears.

Stay tuned.

Local 802 Executive Board member Martha Hyde serves as a trustee on the Local 802 Musicians Health Fund.

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