Navigating the No Surprises Act in 2025: Payer Challenges and Strategic Recommendations

Process management and visibility

Operational strain is real. NSA claims and dispute windows place pressure on payers to manage timelines, administrative fees and compliance. Many still rely on manual workflows, which can lead to delays, penalties or default arbitration losses. Visibility remains limited — arbitration determinations often arrive before parties are even aware an IDR has been filed.

To address this, industry leaders are leveraging technology, analytics and automation to flag high-risk NSA claims and identify IDR trends early. These approaches help strengthen negotiation strategies and reduce unnecessary arbitration, supporting better outcomes for payers and providers. Improvements in documentation and open negotiation workflows are also helping to reduce friction and boost no surprises act compliance.

Provider opposition and arbitration strategies

IDR decisions continue to favor providers. Recent CMS data shows providers win 85percent of cases. As familiarity with the No Surprises Act process grows, some providers bypass open negotiation and heading straight to IDR. Provider arbitration support vendors often win awards that exceed billed charges — posing payment challenges for plans.. Ineligible claims frequently enter arbitration, creating risk for payers and adding strain to the broader NSA system. These errors underscore the need for stronger data validation and eligibility checks.

Data quality and eligibility issues

Data integrity is critical. Errors or incomplete data submitted through the CMS portal can persist throughout the process, skewing outcomes and increasing risk. For example, payers may be named on claims that aren’t theirs, or providers may submit claims within eligible CPT codes, resulting in overpayments. High-quality data is essential for accurate NSA pricing, QPA pricing, and fair dispute resolution.

Best practices include enhancing EOP and EOB messaging to prevent ineligible IDR submissions and closely tracking new resubmission processes to ensure accuracy. Including NSA-specific remark code language can improve outcomes and support No Surprises Act compliance. Provider education during open negotiation also helps reduce IDR escalations and administrative fees — preserving savings on NSA claims.

Education and awareness gaps

Knowledge gaps persist across stakeholders — from members and employersto plan administrators. When understanding of the No Surprises Act is limited, expectations can become misaligned. Employer-focused education and resources are essential to bridge these gaps, empowering members to navigate complex billing scenarios with confidence.

Shifting regulatory landscape

The regulatory environment is dynamic. No Surprises Act 2025 updates and ongoing litigation continue to shift the landscape, making long-term planning difficult.Rising legal costs and pending final rules add even more complexity. Staying informed through timely updates and industry insights is essential for payers to remain compliant and confident.

Strategic steps forward

Payers can move forward by focusing on risk mitigation, collaboration and enablement. Prioritizing open negotiation can help avoid IDR, while advocacy —engaging with CMS or IDR entities to flag ineligible claims or process issues — remains critical.

Educating providers on the benefits of open negotiation is key. The No Surprises Act was designed to encourage good faith negotiations, reduce disputes, shorten time to payment and keep in check for all parties. Building payer-provider collaboration models that emphasize market-based NSA pricing and timely resolution leads to fewer disputes and better outcomes.

Staying ahead in NSA compliance

The No Surprises Act presents significant challenges — but with the right strategies, payers can optimize NSA claim pricing, reduce risk and deliver better outcomes for members. By leveraging technology, data integrity and payer-provider collaboration, Zelis helps you stay compliant in a shifting regulatory landscape.

Want to dive deeper into these strategies or schedule an NSA account review?

Reach out to Zelis for personalized support. And don’t miss Zelis Legislative Weekly — your essential resource for timely updates and expert insights. Stay ahead, stay compliant, and stay confident with Zelis.

Read more:

Navigating the No Surprises Act in 2025: Regulatory Updates for Payers

Navigating the No Surprises Act in 2025: Trends and Insights for Payers