Correction (Feb. 27, 2026): An earlier version of this article stated: “The Third Circuit ruled that arbitrators must presume the QPA is the appropriate payment unless other factors clearly outweigh it. Meanwhile, the D.C. Circuit rejected giving the QPA such privileged status.” The correct information is: “The Fifth Circuit ruled that IDR awards under the No Surprises Act are not enforceable through private litigation, holding that Congress intended enforcement to occur through administrative channels. Meanwhile, the U.S. District Court for the District of Connecticut reached the opposite conclusion, finding that providers may sue in federal court to enforce unpaid IDR awards.”
Since its implementation in 2022, the No Surprises Act (NSA) has transformed how healthcare providers handle out-of-network (OON) claims—but recent months have brought a whirlwind of conflicting news, court decisions, and legislative proposals that can leave even seasoned revenue cycle professionals scratching their heads. We sat down with Nikki Ritchson, Director, Operations at Aspirion, to help cut through the confusion and explain what providers need to know about the evolving NSA landscape.
Q: It feels like every week there’s a new headline about the No Surprises Act—some positive for providers, some concerning. What’s actually happening right now?
Nikki Ritchson: You’re absolutely right that the news cycle has been confusing. We’re seeing simultaneous movement on multiple fronts: court cases, regulatory enforcement, legislative proposals, and state-level actions. The challenge for providers is that these developments don’t all point in the same direction, which creates uncertainty about both current operations and future strategy.
Right now there are two key areas to keep an eye on: 1) H.R 4710, introduced to the House in July 2025. This piece of legislation is also referred to as the No Surprises Act Enforcement Act; and 2) “Cooling off periods” through the IDR process. Payers such as Blue Cross Blue Shield are pushing back against what they describe as high-volume, potentially improper, provider-initiated arbitration, with disputes that are inflated, non-transparent awards. It’s important that providers have safeguards in place regarding the cooling off period and watch the outcome of the payer lawsuits.
Those two factors are going to be key drivers in the future of claims subject to NSA.
Q: Let’s start with the courts. What’s the latest on the legal challenges to the NSA?
Nikki Ritchson: The most significant recent development is actually what didn’t happen. The Supreme Court declined to review lower court decisions regarding the No Surprises Act’s Independent Dispute Resolution (IDR) process. This leaves in place conflicting rulings from different circuit courts about how arbitrators should weigh the Qualifying Payment Amount (QPA)—which is essentially the median in-network rate that insurers are supposed to calculate and provide.
The Fifth Circuit ruled that IDR awards under the No Surprises Act are not enforceable through private litigation, holding that Congress intended enforcement to occur through administrative channels. Meanwhile, the U.S. District Court for the District of Connecticut reached the opposite conclusion, finding that providers may sue in federal court to enforce unpaid IDR awards. The Supreme Court declined to resolve this conflict when it denied certiorari in Guardian Flight, L.L.C. v. Health Care Service Corporation on January 12, 2026.
Q: How does this legal uncertainty affect enforcement of the NSA?
Nikki Ritchson: That’s where things get even murkier. The enforcement landscape is currently in flux. We’re hearing discussions about potential changes to how aggressively federal agencies will enforce NSA provisions, such as those with H.R 4710. What we do know is that providers can’t simply wait for clarity—claims are still being submitted, disputes are still arising, and the IDR process continues to operate under the current framework.
Q: Speaking of the IDR process, how are providers actually performing in these disputes?
Nikki Ritchson: This is one of the more encouraging data points we’ve seen recently. According to analysis of early 2025 determinations, providers won approximately 88% of IDR cases. That’s a significant success rate that demonstrates the value of pursuing these disputes when appropriate.
However, it’s important to understand what these numbers mean—and what they don’t mean. A high win rate doesn’t necessarily translate to high dollar recovery if providers aren’t identifying and escalating the right cases, or if the batching and submission process isn’t optimized. There’s also the question of how many potentially winnable cases never make it to IDR because providers lack the infrastructure or expertise to pursue them.
Q: There’s been talk of legislative changes to the NSA. What should providers be watching?
Nikki Ritchson: Congress is considering legislation that would make significant changes to the NSA framework. H.R. 4710, introduced in the 119th Congress, proposes several amendments to the law. While I won’t speculate on whether or when this legislation might pass, providers should be monitoring it closely because it could fundamentally alter how disputes are resolved and how payments are calculated.
Any legislative changes would ripple through existing workflows, technology systems, and strategic decisions about which cases to pursue through IDR. It’s another layer of uncertainty in an already complex environment.
Q: Beyond the NSA itself, what other out-of-network trends are impacting providers?
Nikki Ritchson: We’re seeing a fascinating and somewhat contradictory set of dynamics in the broader OON space. On one hand, some providers are making calculated decisions to go out of network with certain payers, despite the risks and complexity involved. As one executive noted, “Sometimes these things defy all business logic”—but the decision often comes down to reimbursement rates that simply don’t cover costs, or contract terms that are untenable.
At the same time, we’re seeing payers implement policies that penalize out-of-network care. In Indiana, for example, hospital and provider groups have supported legislation targeting Elevance’s out-of-network penalties, which they argue unfairly shift costs to patients and providers.
Q: You mentioned that different specialties might be experiencing the NSA differently. Can you elaborate?
Nikki Ritchson: Absolutely. The anesthesia community provides a good example of how specialty-specific factors create unique challenges. Anesthesiologists are asking “What’s going on with the No Surprises Act?” because they’re particularly impacted by the law’s provisions around ancillary services provided at in-network facilities.
Anesthesia, emergency medicine, air ambulance, and certain other specialties are more likely to encounter surprise billing scenarios, which means they’re disproportionately affected by how the NSA is interpreted and enforced. The QPA calculation methodology, the factors arbitrators consider, and even the administrative burden of the IDR process can hit these specialties harder than others.
Q: With all this uncertainty and complexity, what should providers be focusing on right now?
Nikki Ritchson: Despite the confusion, there are concrete steps providers can take. First, don’t let uncertainty paralyze your NSA strategy. The law is in effect, disputes are happening, and money is being left on the table by providers who aren’t engaging with the process effectively.
Second, recognize that success in the NSA/IDR environment requires specialized knowledge. The regulatory landscape includes numerous updates and evolving interpretations that impact everything from batching strategies to the supporting documentation that wins cases. Providers need to either build deep internal expertise or partner with organizations that have it.
Third, look at your data. Are you identifying all eligible claims? Are you calculating what you should be receiving versus what payers are initially offering? Are you using unsuccessful contract negotiations to strategically drive claims to the IDR? Are you using IDR winnings to drive contract negotiations with your payers?
Finally, stay informed but don’t overreact to every headline. Yes, there’s uncertainty about future enforcement, potential legislation, and how courts in different jurisdictions are interpreting the law. But the fundamentals remain: ensure compliance, identify underpayment, build strong cases with supporting documentation, and pursue appropriate disputes through the IDR process.
Q: What’s your outlook for the NSA landscape over the next 6-12 months?
Nikki Ritchson: I expect continued uncertainty in the near term, but that doesn’t mean providers should wait for clarity before acting. Legislative changes could emerge, enforcement approaches may shift, and we might see additional court decisions that clarify—or further complicate—how the law is applied.
What won’t change is the need for providers to proactively manage their NSA-related revenue cycle. The difference between a proactive, data-driven approach and a passive one can mean millions of dollars in recovered revenue. With an 88% win rate in IDR disputes, providers who engage effectively are seeing real financial results.
The providers who will thrive in this environment are those who treat NSA/IDR as a strategic revenue cycle function, not just a compliance obligation. That means investing in the right expertise, technology, and processes to identify opportunities and maximize recovery.
For providers looking to navigate the complex and evolving No Surprises Act out-of-network claims landscape, specialized expertise and proven workflows are essential to capturing revenue that might otherwise be lost. Contact Aspirion today to learn how we can help.
