Eliott Dear: The No Surprises Act at Year Three — What Worked, What Failed

The No Surprises Act took effect January 1, 2022. Three years and four months in, the empirical record is in. Some of what Congress promised happened. Most of what Congress designed broke.

What Worked — Patient Protection

The patient-facing balance-billing protection works. A patient who receives emergency care from a non-participating provider at an in-network facility no longer pays the gap between the carrier’s allowed amount and the provider’s billed charge. That was the headline promise. It has been delivered, consistently, across all 50 states.

The Kaiser Family Foundation analyses tracking surprise-bill incidence show approximately 1 million per month would have occurred under pre-NSA rules and are now prevented by NSA protections. That number is real and important. Eliott Dear says it plainly: the NSA was a win for patients.

What Failed — The QPA

The Qualifying Payment Amount mechanism was supposed to anchor IDR awards in transparent in-network median market data. In practice the QPA became a carrier-controlled variable computed from carrier-internal datasets the carriers themselves audit. The Texas Medical Association sued four times. Federal courts struck down four iterations of the QPA methodology. The Departments revised. The cycle continues.

The result for non-par providers: median commercial out-of-network reimbursement has declined 25-40% in most specialties since 2022. Anesthesiology, emergency medicine, and certain surgical sub-specialties have been hardest hit. Provider underpayment did not exist as a category before NSA in the same form; it now dominates non-par revenue cycle conversations.

What Failed — Federal IDR Volume

Federal IDR was projected by CMS to process about 17,000 disputes per year. Actual filings exceeded 2.6 million in 2025. Backlog metrics suggest median resolution times now exceed 200 days. The Fifth Circuit also ruled in 2025 that there is no private right of action to enforce a federal IDR award; CMS, the only remaining enforcement venue, resolves about 1.3% of non-payment complaints.

Federal IDR generates awards. It does not generate cash. Eliott Dear has watched the same pattern play out across dozens of Claims Assassins federal filings.

What Is Coming Next — State by State

State IDR systems have proliferated. New York’s Article 6 §603-d (administered by DFS) has the longest track record and the strongest enforcement. Texas, New Jersey, Connecticut, Georgia, and New Mexico operate their own IDR regimes with state-regulator backing.

The pattern Claims Assassins sees consistently: state IDR awards get paid because state regulators can pull insurer licenses; federal IDR awards do not get paid because CMS cannot. The collection asymmetry is the entire game.

Eliott Dear’s playbook for 2026 and forward: state IDR first whenever the policy is fully-insured in a state-IDR state; federal IDR only when state is genuinely blocked; appeal track for Medicaid Managed Care and Medicare Advantage claims (both blanket-excluded from IDR by statute).