Surprise! Insurers May be Violating the 'No Surprises Act'

The No Surprises Act, a federal law that took effect in January 2022 and aims to make sure patients stay on the same insurance plan when moving from one provider to another, requires insurers to pay hospitals and physicians the same rates for their services regardless of whether they are in-network or out-of-network. This is a boon for consumers, but it also could mean trouble for your insurer if you are receiving QPA benefits. In this post, we will discuss what qualifies as an “outlier” payment amount under the new law and how this may impact your coverage options.

What is the ‘No Surprises Act’?

The recently passed “No Surprises Act” requires insurers to pay hospitals and physicians the same rates for their services regardless of whether they are in-network or out-of-network. This is a huge change for insurance companies, which have historically negotiated with providers based on their own financial needs.

No Surprises Act

The law also limits qualifying payment amounts by setting a minimum cap on how much an insurer can charge per service. In addition, it stipulates that if you choose an out-of-network provider, then your insurer must provide coverage under “preferred provider organization” (PPO) plans until at least 90 days after your treatment ends – even if you don’t want them covering you anymore!

Some insurers are preying on a loophole that allows them to pay some healthcare providers less than others.

This Loophole is called “Qualifying Payment Amounts” (QPAs)

The problem is that insurers have begun altering their contracts with QPA providers so as not to mention QPA altogether. This means that when an insurer has contract disputes with a provider, instead of using the QPA, which could be as much as 60% lower than the standard charges, they will use the much higher standard charges instead. Insurers can then take the savings from not paying out at the lower rate, and use it for other things like stock buybacks or dividends to shareholders.

As a result, many patients may be unaware that they are being charged more than what was initially indicated on their bills—and this could violate state laws that require transparency between patient and doctor regarding payments made by health care providers during treatment sessions (including those associated with procedures).

It is essential to understand what is going on with your insurance company to advocate for yourself and ensure you get fair treatment and coverage.

  • Understand your insurance coverage: When dealing with an insurer, it is crucial that you know exactly what they are paying out in claims payments and how much they will owe after any appeals process has been completed. The only way to do this is by reviewing the policy documents carefully, which should be provided when purchasing a policy from an insurer or broker (this may vary depending upon which state you live in).
  • Make sure that your premiums reflect fair pricing: If this is not happening, contact them immediately! You could also contact their customer service department or file complaints through various channels such as government agencies like The National Association Of Insurance Commissioners (NAIC) who oversee state-level regulation over insurers’ practices related directly back to consumers such as setting up guidelines/laws around certain types of coverages and policies offered by different companies operating within each particular state – so if something doesn’t seem right about how much money someone is making off our backs, then maybe we’d better start looking elsewhere…


The No Surprises Act is a great step towards ensuring that everyone gets the care they need, regardless of insurance status. Unfortunately, it appears as though some insurers are attempting to skirt around this law by altering their contracts with QPA providers. The Act requires that providers are paid for their services upfront, rather than after the fact. Because of this, some insurance companies have been trying to get around this law by asking providers to accept payment terms. If a provider agrees, then they are essentially agreeing to provide services without knowing how much money they’ll be receiving from the insurer. This is no surprise (get it?), and it’s something the powers that be will continue to keep an eye on. The No Surprises Act was designed to prevent situations like this from happening, and continuous monitoring is required to ensure that the law is being followed.

Learn how we can help you processing your Medical billing and codingcontact us online or call us at +1-307-368-8003 or Email us at

Danielle Ezra

Executive – Social Media Marketing

V-Etico Services LLC

Phone: 1 (307) 368-8003