ASA Recommendations on No Surprises Act Implementation

By July 19, 2021Uncategorized

On January 1st, 2022, the Biden administration’s “No Surprises Act” will be implemented in medical practices throughout America. The bill intends to protect patients from additional unanticipated medical bills following treatment while also establishing an independent dispute resolution for physicians to demand fair payment from health insurers. While the legislation is a promising step towards greater clarity on the financial component of healthcare, there remain some uncertainties about how this change will alter the ever-complicated relationship between physicians and health insurers. To this end, the American Society of Anesthesiologists (ASA) generated a list of recommendations for the implementation of the No Surprises Act.

The recommendations are included in an 11-page document addressed to the U.S. Department of Health and Human services, the U.S. Department of Labor, and the U.S. Department of Treasury, and are organized into five key categories: independent dispute resolution, qualifying payment amount and initial payment, patient engagement, interaction with state laws, and auditing. The ASA requests in particular that the process for independent dispute resolution be transparent by weighing all factors equally in the determination of payment and explicitly stating an intention to do so. According to the document, these factors include:

“the QPA, any additional information requested, the provider or facility’s level of training and experience, and the parties’ market shares, among other factors…We believe it is necessary for the Departments to be specific as to these considerations so the IDR process is standardized and does not vary significantly from one entity to the next. Even in the best of circumstances, these factors are subjective and will be assessed differently by each arbiter.”[1]

The list of recommendations also includes a demand for active commitment towards the reduction of biases in the settlement of payment disputes.

Moreover, the ASA requests that calculations of insurer’s median in-network amounts are done both accurately and fairly. The letter mentions the number of variables that can affect the cost of healthcare dramatically, including zip code, specialty, physician’s level of training, the frequency of payments, and several other factors. According to the ASA, the No Surprises Act does not specify its plans to determine median in-network amounts, and to not consider these factors would result in inaccurate payments and provide ample opportunity for healthcare insurers to underpay physicians.

One of the final notable components of the ASA’s requests is the demand that physicians be able to access the federal independent dispute resolution process. The ASA argues that in states where similar legislation to the No Surprises Act is already being implemented, the interaction between state and federal law would place too much strain on physicians. The letter states:

“We are concerned that the interaction of these federal and state frameworks will result in a patchwork scheme that creates tremendous uncertainty about which laws apply, placing the burden on parties to analyze which regulatory scheme they fall under. We believe this is asking too much of providers and patients. Providers’ primary concern is patient care and patients’ primary concern is obtaining the care needed to promote good health. We urge the Department to never lose sight of these important objectives.”1

While the No Surprises Act has the potential to change the landscape of healthcare payment for both patient and physician alike, there remains the need for increased clarity. The ASA’s recommendations offer an actionable template for equitable implementation.


[1] ASA Makes Recommendations to Biden Admin: Implement ‘No Surprises Act’ Equitably Without Improper Advantage to Health Insurers. (2021). Retrieved from