The letter outlines growing evidence that some health plans are circumventing the intent of the NSA by shifting costs to patients, withholding or delaying payments owed to physicians, and exploiting gaps in the independent dispute resolution (IDR) process. These actions jeopardize both patient protections and the financial viability of physician practices.
Key issues highlighted in the letter include:
Cost‑shifting to patients after IDR decisions: Some plans are reprocessing claims and increasing patient cost‑sharing following IDR rulings in favor of physicians — “a practice that is clearly in violation of the spirit, if not the language, of the NSA.”
Improper reopening of closed IDR cases: Plans are using June 2025 technical guidance to reopen settled cases without sufficient cause, delaying or avoiding required payments despite the guidance stating that payment should proceed.
Ineligible claims entering the IDR process: Limited transparency from payers makes it difficult for physicians to determine eligibility, and plans frequently fail to participate meaningfully in open negotiations or IDR, contributing to default decisions.
Lack of transparency in Qualified Payment Amount (QPA) calculations: Physicians report that QPAs do not reflect market rates, and plans are not required to substantiate how these amounts are calculated or provide supporting data.
Failure to issue timely and complete payments: Many plans are not paying IDR awards within the required 30‑day window, issuing partial payments, or failing to pay altogether. The letter cites survey data showing that 22 percent of IDR awards in 2023 and 11 percent in 2024 remained unpaid.
The coalition urges federal agencies to strengthen enforcement, improve transparency, and ensure that health plans comply with statutory requirements. These steps are critical to preserving patient protections and maintaining access to care.
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