Fair payment may remain elusive for certain physicians practicing under the U.S. federal No Surprises Act and its independent dispute resolution (IDR) process, according to Rich Heller, MD, who takes up the issue in Episode 17 of the Keeping Up with the Radiologists podcast from AuntMinnie and Penn Radiology.
With host Saurabh (Harry) Jha, MD, Heller, a pediatric radiologist and chief medical officer at Radiology Partners, discusses the No Surprises Act (NSA)'s rocky road since January 1, 2022, when the statute went into effect, establishing the IDR process for settling payment disputes between providers and insurers.
The impact of IDR can be seen initially on the U.S. Centers for Medicare and Medicaid Services (CMS) website. CMS has highlighted both an influx of IDR initiation requests, a backlog of unresolved disputes, and the rise of third-party entities working as arbitrators. July 2025 saw more IDR initiations than the total number of disputes submitted in IDR’s first year, according to CMS.
AuntMinnie members may have read that one of the consequences of IDR is the termination of existing agreements with providers and lower physician payment rates.
"Their agenda was to disrupt the normal good-faith network contract negotiations that happen between a medical practice and an insurance company," Heller said during the podcast. "The debate was never about is surprise medical billing good or bad."
The issues have not been with the law itself, but rather with choices made in implementation of the law and the opportunities it has created for insurance companies and third parties to make money at the expense of physicians, he explained.
Under the No Surprises Act, if a physician or a practice considers the payment offered by an insurer to be inadequate, they can challenge the payment through the IDR process, which throughout 2025 has been scrutinized.
Arbitration under the NSA can be expensive, time-consuming, and it can take six or more months for physicians to get paid, Heller noted. Interestingly, he also explains how insurance companies use the shared savings incentive to make money off of reducing physician payments.
"You will very quickly see the math," Heller said. "They have an incentive now, financially, to drive physicians out of network and then pay as little as possible so they can drive that shared savings fee. ... The fees to process the claim were more than the actual care delivery itself," he added, noting that third-party companies help insurance companies drive physician payment rates down.
When the independent arbiter rules in favor of the physician, the insurer must pay within 30 days. However, reports are that insurers often fail to pay in a timely manner. There is pressure to resolve this issue, but further action is necessary, according to Heller.
Bipartisan legislation
In hopes of corrective action, the American College of Radiology (ACR) has endorsed the No Surprises Enforcement Act, H.R. 4710/S. 2420. If successful as written, the bipartisan legislation will fine health insurance companies that fail to pay physicians within 30 days after losing the IDR process laid out in the NSA.
Neither bill has moved since its introduction and committee referral on July 23, 2025, but their provisions would impose a penalty equal to three times the difference between the insurer’s initial payment and the IDR entities’ ruling per claim. Furthermore, the claim will also be subject to interest, supporters have noted.
Qualifying payment amount (QPA) calculation -- the term the statute created for the “median contracted rate” -- remains a significant issue on several fronts, according to the ACR. The issue leaves providers with nowhere to go when health insurers present patently incorrect QPAs, according to authors of an October 2025 letter urging the release of the IDR Operations final rule (CMS-9897).
"The federal IDR process is currently in an extremely unstable state, with many insurers ... using incorrect information to make payment determinations," the authors wrote.
CMS-9897 was listed on the administration’s unified agenda for November 2025 action and has been highlighted for its potential to alleviate the QPA issue. The payment amount is measured by the median in-network contracted rate. As higher-paying contracts fall away, QPA can effectively be manipulated to lessen its value as a fair measure of the market.
Lobbying efforts
In their letter, the ACR, American College of Emergency Physicians (ACEP), and American Society of Anesthesiologists (ASA) recommended that "finalizing the requirement to use [remittance advice remark codes] RARCs and [claim adjustment reason codes] CARCs that identify which protections govern the claim for all claims will give providers the necessary information to assess patient cost-sharing amounts, keep patients out of the middle of the process, and reduce the instances in which payment disputes are initiated in the wrong jurisdiction."
ACR, ACEP, and ASA also called for greater transparency through the federal IDR portal and IDR registry requirements. Some of that may already be underway.
Listen to Episode 17 for Heller's perspective on the No Surprises Act. Plus, during the second-half segments, Heller discusses practicing radiology at scale, radiologist autonomy, impact of consolidation in the House of Medicine, and more.
More impressions:
{02:36:00} No Surprises Act introduced
{04:10:00} Physicians in network, out of network
{05:02:00} Agendas
{08:16:00} Independent dispute resolution (IDR)
{11:24:00} Benchmark rate
{15:25:00} Financial incentives
{30:17:00} Private equity's part
{43:55:00} Getting into advocacy
{51:54:00} MIPS program
{55:03:00} Perfect storm in radiology
{58:02:00} Medicare payment reform
{58:37:00} Health policy or advocacy challenges
Featured
Richard Heller III, MD, pediatric radiologist and senior vice president of health policy at Radiology Partners. Heller also serves as clinical associate at University of Chicago. His academic work centers on the economics of healthcare. He is a frequent national speaker, and his writing has appeared in Radiology and the American Journal of Roentgenology (AJR). He also has served on the board of the Radiological Society of North America (RSNA) and will become a trustee of the RSNA Research and Education Foundation. Within the American College of Radiology (ACR), Heller chairs economics-focused committees and contributes to the Society for Pediatric Radiology through various activities, including his role on the editorial board of Pediatric Radiology.
Host
Saurabh (Harry) Jha, MD, is an associate professor of radiology at the Hospital of the University of Pennsylvania. Jha obtained a master’s degree in health policy research from the Leonard Davis Institute at the University of Pennsylvania. He earned his medical degree from the United Medical and Dental Schools of Guy’s, King’s, and St. Thomas’ Hospitals. Jha developed Value of Imaging, a set of radiology educational resources.
This episode of Keeping Up with the Radiologists is brought to you by AuntMinnie.com in collaboration with Penn Radiology. Check back for new episodes!
