The No Surprises Act (NSA) changed how out-of-network billing works, but for health plans, payers, TPAs and providers, the operational pressure has not slowed down.

That volume tells a clear story: NSA compliance is not a one-time project. It is an ongoing operational discipline that requires accurate claim identification, defensible QPA calculations, structured open negotiation, disciplined IDR case management and audit-ready documentation.

The goal is not just to check a compliance box. It is to reduce avoidable disputes, control costs, protect members and make the process easier for everyone involved.

What Is the No Surprises Act?

The No Surprises Act (NSA) took effect on January 1, 2022, and it was designed to protect patients from unexpected medical bills when they receive certain out-of-network services. These situations often happen when a patient does not have a real choice in who provides their care.

Before the NSA, patients could be billed for the difference between what an out-of-network provider charged and what their health plan paid. The NSA limits that exposure in covered scenarios, so patients are generally responsible only for their in-network cost-sharing amount.

For payers and providers, the law created a formal process for resolving payment disputes. That process starts with an initial payment or denial, moves into open negotiation and may end in federal independent dispute resolution.

Which Claims Does the NSA Cover?

The NSA generally applies to three main types of services:

1. Emergency services provided at covered facilities, regardless of whether the provider is in network
2. Non-emergency services from out-of-network providers at in-network facilities when the patient did not have a meaningful opportunity to choose an in-network provider
3. Air ambulance services provided by out-of-network carriers

In these situations, patients may only be billed their in-network cost-sharing amount, and any remaining payment disagreement must be resolved between the payer and provider.

That makes claim identification one of the most important parts of NSA compliance. Not every out-of-network claim falls under the law. Some claims may be governed by state law, standard out-of-network payment terms or other rules.

When claims are misclassified, the consequences can add up quickly. Organizations may face unnecessary disputes, incorrect member cost-sharing, compliance risk and avoidable administrative costs.

What Is the Qualifying Payment Amount?

Qualifying Payment Amount (QPA) is the payer’s median contracted rate. Health plans use it to determine member cost-sharing under the No Surprises Act (NSA), and it’s a key factor in Independent Dispute Resolution (IDR).

Getting the QPA right matters. It’s how health plans stay compliant — and how providers know if a payment is fair.

How NSA Payment Disputes Are Resolved

When a provider disagrees with a payer’s initial payment or denial for an NSA-covered service, the law lays out a structured path.

1. Initial Payment or Denial

The payer issues an initial payment or denial and provides required information, including the QPA and applicable NSA disclosures.

This step matters more than it may seem because missing information, incorrect codes or unclear payment rationale can create confusion and trigger downstream disputes.

Clear remittance advice and consistent documentation help both parties understand the decision and decide whether further negotiation is appropriate.

2. Open Negotiation

Before either party can initiate IDR, they must participate in a 30-day open negotiation period. This is the best chance to resolve the dispute before it becomes more expensive and time-consuming.

Open negotiation should not be treated as a formality. It is a real opportunity to:

• Reduce IDR volume
• Lower administrative costs
• Resolve disputes faster
• Preserve payer-provider relationships

Effective open negotiation depends on clear communication, organized evidence, documented outreach and teams that understand the NSA process.

3. Independent Dispute Resolution

If open negotiation does not resolve the dispute, either party may initiate IDR through the appropriate federal or state process.

In federal IDR, both parties submit payment offers and supporting evidence to a certified IDR entity. The IDR entity then selects one offer. There is no splitting the difference.

That makes preparation important. Each party needs to understand:

• How its offer compares with the QPA
• What evidence supports its position
• Whether the dispute belongs in federal IDR at all

Federal IDR does not apply in every situation. If a state has an applicable All-Payer Model Agreement or qualifying dispute resolution process, the state process may apply instead. For organizations operating across multiple states, accurate routing is essential.

Operational Priorities for NSA Compliance at Scale

NSA compliance touches many areas of a payer’s claims operation and a provider’s revenue cycle. At high volumes, manual processes can become risky and expensive.

Four priorities matter most when organizations are trying to manage NSA compliance at scale:

1. Identify Covered Claims Accurately

Every NSA workflow starts with one question: does this claim fall under the law?

Answering that requires claim-level screening based on:

• Plan type
• Service type
• Facility status
• Provider network status
• Geography
• Applicable state rules

If an ineligible claim moves into negotiation or IDR, both parties may waste time and incur unnecessary fees.

2. Build a Defensible QPA Process

QPA calculation must be accurate, consistent and well documented.

Payers need strong data infrastructure, clear methodology and audit-ready records. If a plan does not have enough contracted rate data, it may need to use an eligible third-party database or another methodology consistent with federal guidance.

3. Take Open Negotiation Seriously

Avoiding IDR is often faster and less expensive than winning IDR for payers, and a strong open negotiation workflow gives both sides a better chance to resolve disputes before arbitration.

That means having:

• Clear intake processes
• Standardized documentation
• Defined response timelines
• Communication strategies that reduce confusion

It also means using data to understand which disputes are likely to resolve through negotiation and which patterns are driving repeated escalation.

4. Maintain Reporting and Audit Readiness

NSA compliance is subject to ongoing oversight, so payers need to show compliance across the full claims lifecycle, from initial pricing to final dispute resolution. Providers also need records that support dispute submissions and help track payment patterns.

Useful reporting should include:

• Dispute volume
• Open negotiation outcomes
• IDR escalation rates
• Payment outcomes relative to QPA
• State versus federal routing
• Provider-level trends

The strongest NSA strategies are proactive. They use reporting to spot risks early, improve workflows and make better decisions over time.

Reducing Friction Between Payers and Providers

Provider abrasion is one of the biggest hidden costs of NSA compliance. Payment disputes, delayed resolution, unclear communication and inconsistent methodology can all strain payer-provider relationships, and over time, that friction can lead to more escalations and more administrative burden.

Reducing friction starts with clarity. Payers that explain their NSA pricing approach, provide accessible dispute pathways and respond promptly during open negotiation are more likely to prevent unnecessary escalation.

Education also helps. When both sides understand the process, disputes are easier to manage and less likely to become adversarial.

The NSA also sets transparency requirements. These include Good Faith Estimates for uninsured and self-pay patients, plus the planned Advanced Explanation of Benefits (AEOB) for insured patients.

Together with Transparency in Coverage rules, these requirements all depend on accurate rate data. That data supports QPA calculations, cost estimates, public disclosures and dispute outcomes.

What to Look for in an NSA Compliance Partner

At current dispute volumes, NSA compliance takes more than policy knowledge. Organizations need operational support that can scale and rapidly flex to meet changing regulatory requirements.

A strong NSA compliance partner should support:

• Claim pricing
• QPA calculation
• Eligibility screening
• Open negotiation
• IDR case management
• Member balance bill support
• Audit documentation
• Reporting

The right partner should also bring defensible methodology, workflow automation, regulatory expertise and actionable analytics. That combination helps organizations reduce ineligible disputes, strengthen open negotiation, monitor IDR trends and maintain audit-ready records.

The goal is not just to win individual disputes. It is to build a program that reduces dispute volume, controls cost, protects members and improves collaboration between payers and providers.

Build a Compliance Program That Scales

NSA strategies continue to be impacted by regulatory changes, litigation activity, state law changes and market behavior. Organizations that rely on manual workflows or fragmented systems face growing cost pressure and compliance risk.

The organizations best positioned for success treat NSA compliance as a scalable operating model. They invest in defensible QPA documentation, structured negotiation workflows, accurate IDR support and reporting that supports continuous improvement.

Zelis helps organizations build defensible NSA performance programs — from QPA calculation through dispute resolution. With Zelis NSA Claim Advantage℠, we help enable payers to continuously optimize outcomes, improve win rates and maximize savings. Connect with us to learn how the right combination of technology, data and expertise can help reduce friction, control costs and protect the member experience.