When the No Surprises Act (NSA) took effect, it was widely viewed as a major step forward in protecting patients from unexpected medical bills and curbing excessive out-of-network pricing. It created clear standards around balance billing, established payment frameworks and introduced the federal Independent Dispute Resolution (IDR) process to help resolve payment disagreements between plans and providers.
However, the law left one critical element large unresolved: enforcement.
aequum was featured as The Granite List’s Industry Expert of the Week where we discussed the growing gap between the NSA’s intent and how it plays out in practice – a challenge that many plan sponsors have been confronting firsthand.
The Enforcement Gap Plan Sponsors Face
The NSA created new compliance requirement for plans and providers, but it is obvious that enforcement remains fragmented and largely complaint driven. Responsibility is spread across multiple federal and state agencies, and there is no systematic monitoring of provider behavior. This leads to issues such as improper balance billing, aggressive collections or questionable dispute tactics surfacing only after plans and participants have already felt the impact.
Self-insured employers, then, are put in a difficult position as plan sponsors still carry fiduciary responsibilities to protect plan assets and participants, even when the other side may be pushing the boundaries of the law. Identifying violations, documenting claims decisions and managing disputes require resources and a proactive strategy.
Legal Uncertainty Adds Another Layers
At the same time, ongoing litigation continues to shape how the NSA will ultimately function. Courts have issued conflicting rulings on key issues such as how Qualifying Payment Amounts (QPAs) are calculated and how IDR determinations should be treated.
Meanwhile, the Supreme Court of the United States has declined to take up recent cases addressing whether the law creates a private right of action for providers to enforce IDR awards, leaving lower court decisions in place and further placing uncertainty.
These enforcement failures and legal uncertainty compound the enforcement gap and create further exposure for plan sponsors. Until clearer regulatory and judicial guidance emerges, protecting a health plan requires more than just following the statute. It also requires active monitoring, strong documentation and experienced advocacy when disputes arise.
Where aequum Helps Plans Defend Themselves
Compliance alone is not enough and plans increasingly need partners who can operate in the space between the law’s framework and the realities of enforcement. aequum supports self-insured plans by:
• Identifying NSA violations and improper provider conduct early, before claims escalate.
• Defending against balance billing, out-of-network overcharges and inappropriate collection activity.
• Managing and supporting disputes when claims move into IDR.
• Preserving plan rights through accurate documentation and defensible reimbursement positions.
• Using data, transparency files and claim analytics to challenge inflated demands.
• Providing legal advocacy when provider behavior crosses from aggressive into abusive.
The NSA created an important framework for protecting patients and controlling out-of-network costs but it didn’t eliminate the need for active defense. aequum functions in the space between stator intent and real-world execution, defending plans and participants when enforcement is slow, unclear or ineffective.
Contact us today to evaluate where your plan may be exposed and how stronger protections can be put into place.