These include emergency services, ancillary services such as anesthesia, and elective procedures performed at in-network facilities.
While the law removes the patient from the billing dispute, it shifts the burden to healthcare providers and insurance carriers.
For providers, the NSA fundamentally changes how out-of-network services are paid. Insurance carriers issue an initial payment based on the Qualifying Payment Amount (QPA), which is intended to reflect median in-network rates.
In practice, these payments are often significantly lower than expected reimbursement. Without further action, the QPA amount is typically all a provider will receive.
The NSA established an arbitration system called Independent Dispute Resolution (IDR), which gives providers a way to challenge low insurance payments and pursue fair reimbursement.
After the carrier issues its initial payment, the provider can open a dispute and submit evidence to support a higher rate. The insurance carrier does the same. A neutral, certified third party then reviews both sides and is required to choose one of the two payment amounts.
For providers, this process can make a big difference. Those who pursue IDR often recover far more than the initial payment, in many cases ranging from 10x to 100x the QPA.
Many providers enter the NSA process without a clear understanding of its complexity. Common issues include:
Carriers frequently challenge filings on minor technicalities, including data entry errors, to avoid paying IDR awards.
Even when providers win, payment isn’t always guaranteed. In fact, roughly 45% of awards require escalation to secure payment. This is when legal intervention becomes necessary.
An experienced NSA law firm like Gottlieb & Greenspan plays a critical role in enforcing awards and holding insurance carriers accountable.
We support providers by:
Every client is assigned to a dedicated senior paralegal and team, so your case gets the attention it deserves.
