No Surprises’ Second Act: Closing Loopholes and Keeping Patients in the Loop

It’s been nearly five years since the No Surprises Act (NSA) became law. Its goal is to protect patients from unexpected medical bills due to out-of-network care, yet many feel it has failed to deliver. Compliance has been weak and enforcement spotty, with patients being kept in the dark about healthcare costs. NSA requires health plans to verify provider information every 90 days – and payer databases are to be updated within 48 hours of receiving new details. With hundreds of thousands of in-network providers, administrators face a near-impossible challenge to remain compliant. 

This may soon change. On February 25, 2025, the White House issued a new executive order mandating clear, accurate and actionable healthcare pricing information. This put insurers and providers on notice that there will be no more loopholes to exploit. Specifically, the Departments of Health and Human Services, Labor and Treasury were instructed to “rapidly implement and enforce” regulations, while ensuring actual prices were disclosed, not estimates.  

While progress remains to be seen, this does serve as a reminder that we have a major, unresolved problem on our hands. Americans, accustomed to being able to compare prices on everything from flights to refrigerators, can’t do the same when it comes to healthcare. Why is the industry still such a black box when it comes to information? The answer lies in data quality. And without accurate, standardized and accessible payer and provider data, even the strongest policy measures are going to have a tough time.

The devil is in the details

The No Surprises Act has been locked in litigation, plagued by implementation issues and picked apart by those trying to find a way around it. While the latest executive order aims to put some teeth behind it, the underlying issues of incomplete, and worse, inaccurate data is nothing new and won’t go away easily. 

In 2023, it was found that four of five entries in the leading five U.S. health plans were inaccurate. This doesn’t just result in minor patient inconvenience, it can produce financial chaos and impede and possibly prevent medical treatments. Yet, even as patients trust health plan directories for such basic and critical purposes as selecting practitioners, inaccurate and incomplete data is common, as are resulting process issues for all involved. 

A big reason for this is medical provider information – from contact details to affiliate networks – changes frequently and quickly. For administrators to manually make updates consumes a lot of resources, costing U.S. physician practices nearly $3 billion annually. Making matters worse is the absence of effective data standards: Not only does the average practice deal with dozens of health plans, but each usually has its own way of sharing directory data. 

As one might expect, complex systems like these aren’t always going to link patients with the correct provider. So, let’s say a plan makes an error and lists an out-of-network provider as being in-network. Patients can end up with that shockingly high bill, while seeing more of their own funds leaving their pockets, potentially followed by claim denials and timely care being missed. 

What’s more, wrongly directed medical funds are bound to get even closer scrutiny. Our own research revealed Medicaid members – not assigned correctly due to bad data – are responsible for nearly $55 million in unnecessary spend in just one month, in a single health system, and in only one state. The devil is in the details and ongoing healthcare staffing shortages and increased burnout are not helping. 

Get your facts straight

A provider can improve clinical and financial outcomes with accurate and up-to-date data. The directories that have the correct information will connect patients with the best care providers. This is particularly true when it comes to patients with chronic, severe, and difficult issues requiring synchronized care from several teams. Clean data drives correct referrals, appointment scheduling, timely follow-ups, and more, reducing the chance of treatment being delayed or missed.

Accomplishing this requires systems that deliver data accuracy through automated updates in real time. With the right data management, admin functions can be streamlined, incorrect billing and claim denials prevented, and those charges stemming from in/out-of-network provider inaccuracies eliminated. Further, the less manual entry, the less likelihood of human error, and staff are freed up can focus more on patient care and services. 

Healthy data means healthy compliance, too. This even applies to the No Surprises Act, which requires provider directories to receive timely and accurate updates. And if not, fines, damaged reputations, and patient trust could follow.

Closing loopholes, keeping patients in the loop

Healthcare needs to embrace robust, data governance frameworks that incorporate policies and procedures for high data availability, usability, and security. Following that, insurers and medical providers have to collaborate, and, iron out how data management responsibility is going to be cooperatively handled.

Basically, healthcare needs to close data loopholes and do a better job of keeping patients in the loop. This can be done with solutions that are already available, specifically, platforms that can standardize and synchronize data, regardless of health plans. Research has shown this technology can help providers save an average $1,250 monthly in administration costs, while providing the U.S. more than $1 billion in savings annually. 

Accomplishing this will necessitate payers and providers to invest in mutually beneficial technology. A lack of data management control and error-laden provider directories won’t go unnoticed, especially in a time of increased scrutiny – and it shouldn’t. Agnostic platforms can provide that accurate, synchronized data that’ll lower costs, improve efficiency and elevate care.