2026
Quarterly Newsletter

NSA Report on Aggressive Provider Billing

The No Surprises Act was designed to protect patients from unexpected medical bills. But what is happening behind the scenes to employer-sponsored health plans?

In this national analysis, The Phia Group examined 1,256,822 federal IDR disputes across all 50 states to uncover emerging provider billing and arbitration trends. The data reveals a pattern: In certain markets, arbitration is increasingly being used not simply to resolve disputes, but to maximize reimbursement.

Our report identifies:

• States with the highest concentration of high-risk provider behavior
• Billing and arbitration trends driving elevated employer payouts
• Volume hotspots where a small cluster of providers accounts for disproportionately high dispute activity
• Data-backed insights to help plans anticipate cost exposure

The findings highlight the reality that while patients are protected from surprise bills, employer-sponsored plans may be absorbing the financial impact of aggressive billing and arbitration strategies.

DOWNLOAD THE REPORT

Service Focus (and Enhancement!) of the Quarter: NSA/IDR

Phia’s NSA/IDR service offering continues to evolve alongside the realities of the No Surprises Act (NSA), where compliance alone is no longer enough. Plans and TPAs are increasingly looking for support that does more than simply react to disputes after they arise; you need a partner that can identify patterns, evaluate exposure, and help shape a more informed reimbursement and dispute strategy from the outset.

To make sure that we can be that partner, Phia’s Provider Relations team has created a national report on aggressive provider billing, which we view as not just great information, but an enhancement to our NSA and IDR support service itself, giving our team and our clients access to broader market insight that can inform day-to-day NSA and IDR decision-making. Since the NSA is complex and IDR requires a great deal of forethought, this report is designed to make the process more efficient and predictable for our clients.

Rather than treating each payment dispute as an isolated event, the report helps place individual claims into a larger context. By analyzing nationwide dispute activity, highlighting patterns, and predicting provider behaviors, it gives Phia’s NSA/IDR team another tool to assess where billing practices may reflect broader strategic trends instead of ordinary reimbursement disagreement. That kind of perspective can strengthen client guidance at every stage of the process by tying individual matters to larger market trends.

More broadly, this positions the service as both operational and analytical. Your client health plans need help meeting deadlines or navigating IDR mechanics, but they also need practical insight into how the system is being used, where pressure points are developing, and how plans can respond in a way that is both compliant and cost-efficient. In that vein, this report deepens the intelligence behind the service, allowing Phia to pair hands-on NSA/IDR support with a wider view of the reimbursement environment its clients are facing.

Phia Case Study: Medicare Secondary Payer Act

We frequently encounter situations where health plans want to use Medicare to their advantage. It’s understandable; as another payer, Medicare provides significant potential financial advantages to a group health plan.

The trouble is that the law has accounted for this. In the form of the Medicare Secondary Payer Act, federal law prohibits group health plans from taking into account an individual’s Medicare eligibility or enrollment status. Through that very broad prohibition, federal law slams the door shut on benefits such as trailing spouse continuation options (i.e., where an employee is incentivized to leave the health plan in favor of Medicare by granting the employee’s spouse special continuation rights).

Trailing spouse provisions aren’t the only way a plan can inadvertently violate this federal law, though. Plan provisions that purport to “coordinate” with Medicare, when the enrollee has not enrolled in Medicare, are equally problematic, and more common.

Simply put, if an individual is penalized for not enrolling in Medicare, or incentivized to leave the plan in favor of Medicare, that presents a compliance problem.

If your plan (or a client’s plan) has language that you think fits this mold, please contact The Phia Group as soon as possible!

Fiduciary Burden of the Quarter: Vendor Oversight

The legal landscape surrounding health plans is a broad one. At any given time, there are a dozen (or dozens!) of compliance matters to think about. Luckily for health plans, they’ve got TPAs and broker partners to help manage all this. But what happens when a vendor tasked with performing delegated plan duties doesn’t perform those duties in a way that meets the plan’s own responsibilities?

Legally, very few duties related to plan administration and claims processing fall to anyone but the plan itself. Plans obviously contract out most of these important specialized functions but contracting them out doesn’t relieve the plan of the ultimate responsibility to satisfy its own legal duties. That’s why there’s an important fiduciary duty inherent in not just vetting and choosing vendors, but in maintaining continued oversight. Making sure that vendors are helping plans comply with their duties, rather than operating in a way that falls short, is a crucial part of a plan’s everyday fiduciary responsibilities.

The hard part is that vendor problems rarely announce themselves with fanfare; more often, they show up as mismatches between contract language, procedural workflows, and claims outcomes. Trust is a foundational necessity, but trust alone cannot ensure fiduciary prudence. Outsourcing duties to vendors does not outsource the plan’s legal responsibility, so plans must act prudently and diligently in making sure their vendors are performing services in a manner consistent with the plan’s governing documents, administrative expectations, and legal obligations.