The EDPMA Solutions Summit brings practice administrators, physician groups, and RCM professionals together to share what is working, what is not, and where the opportunities are. This year, beneath the practical discussions of IDR strategy, payer negotiations, and automation, a quieter theme kept surfacing: between regulators and the courts, the forces shaping this space are either out of alignment with provider reality or ill-equipped to enforce existing mandates.
Understanding the lay of the land is the first step to operating effectively within it. While we wait for the gears of government to turn, the most successful practices are taking the wheel themselves.
During the Keynote Fireside Chat with Jeff Wu, Deputy Director for Policy at CCIIO & CMS and Randy Pilgrim, MD, FHPC Chair, Mr. Wu indicated it accepts payers withholding payment even after an IDR judgment if the payer believes claims were ineligible. As a member of CCIIO's senior leadership team, Mr. Wu has significant insights on health policy and regulatory domains that affect emergency medicine. This shocking statement applies even when the payer failed to raise objections during the process, and there are no timeline requirements for reopening a case.
With oversight divided across federal and state jurisdictions and limited audit capacity, the working standard from a compliance perspective is largely assumed, and meaningful improvements to that remain uncertain. Any audits that do occur focus on consumer impact, not provider payment.
H.R. 4710, Congressman Greg Murphy’s bipartisan legislation, would introduce real enforcement tools and is advancing through advocacy from EDPMA leadership and the broader provider community. The operations final rule is expected in the near term, though no specific timeline was confirmed at the Summit for when this is expected to go live. Private right of action to pursue awards based solely on IDRE judgement, another potential enforcement avenue, has been rejected by 45 of 48 judges across relevant cases.
For providers who have done everything right and won, this is a real operational problem.
External sentiment treats payer and provider outliers in the IDR process as equivalent problems. A provider error leading to an outsized award is weighed against confirmed payer strategies of non-payment and fractional offers. That framing does not reflect what is actually happening.
Payers have built coordinated, well-resourced approaches to down-coding, claim denial, and IDR engagement. Most provider organizations are working through cases individually, without that scale of infrastructure behind them. Payers are also insulated from the financial consequences of IDR losses through Shared Savings arrangements, which weakens the deterrent those outcomes are supposed to create. Improvements to remit data that would help providers identify NSA-eligible claims more accurately depend entirely on payers acting consistently and in good faith, with no enforcement mechanism requiring them to do so.
When payers can 'reopen' a case at any time, your system needs to do more than just file; it needs to audit. Automation allows you to track every 'win' against actual bank deposits, instantly flagging those eligibility-based withholdings for your legal team.
The asymmetry between payers and providers is real, but it is not fixed. Payers have invested in data, automation, and process to work these frameworks to their advantage, and providers who make similar investments are seeing the difference.
Strong IDR case management and strong contract negotiation leverage are not separate goals. They draw from the same foundation of clean data and operational discipline. The aim is not always to be combative. Done right, out-of-network outcomes become the evidence base for fair and reasonable in-network contracts, turning a reactive process into a proactive negotiating tool. Closing that gap is achievable, but it typically requires outside expertise and the right partners to get there.
Regulatory improvements will come, and provider advocacy is making a difference. But the organizations gaining ground right now are not waiting. They are building the infrastructure and finding the partners that let them operate effectively today.
The No Surprises Act was designed to protect patients, but it has still rewarded payer scale. The only way to win an uneven game is to change how you play it. By moving from manual workflows to automated data engines, you don't just recover value, you reclaim the leverage you need at the negotiating table.
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