The No Surprises Act (NSA) was designed to shield patients from unexpected medical bills, but its promise to protect physician payments is falling short. Even when independent practices win 85% of Independent Dispute Resolution (IDR) cases against insurers, victory doesn't mean a check in the mail. Insurers — particularly large, publicly traded ones — have financial incentives to delay payments, a practice known as "holding the float," where they invest owed funds before paying out. A 2025 Fifth Circuit ruling made things worse by blocking providers from suing in federal court to collect unpaid awards, leaving enforcement to a slow administrative complaint process.

The fallout is hitting independent practices hard. With 84% reporting higher operating costs in 2026 and margins shrinking, many are being forced into consolidation. Hospitals, insurers, and private equity firms acquired nearly 13,900 physician practices between 2024 and 2026, and over 80% of physicians are now employed by non-independent entities.

By the Numbers:

• 85% — provider win rate in IDR payment determinations
• $2.1M — amount two providers claim Anthem owes across 147 IDR cases
• ~13,900 — physician practices acquired by hospitals, insurers, or PE firms (2024–2026)
• 80%+ — physicians now employed by hospitals, health systems, or corporate entities

Why it matters: When independent practices can't collect what arbitrators say they're owed, the entire physician independence ecosystem erodes. Proposed reforms — including the NSA Enforcement Act, which would penalize insurers for late payments — could be a critical lifeline for keeping independent medicine viable.