Since the implementation of the No Surprises Act (NSA) in January 2022, out-of-network (OON) reimbursement has become a complex and resource-heavy challenge for hospital and health system revenue cycle leaders. Although designed to shield patients from unexpected medical bills, the legislation has placed continuous financial pressure on hospitals and health systems, leading to delayed payments, operational burdens, and strained resources.
The Dispute Backlog: Delayed Payments, Growing Frustration
Between April 2022 and June 2023, providers submitted over 490,000 disputes under the NSA, with 61% still unresolved, according to FTI Consulting. For revenue cycle executives, this represents not just delayed payments but also significant disruptions to cash flow, forecasting challenges, and additional stress on already overburdened teams.
However, there is a silver lining: providers are winning the majority of disputes. Data from the U.S. Department of Health and Human Services (HHS) shows that providers prevailed in 77% of nearly 84,000 Independent Dispute Resolution (IDR) cases in the first half of 2023, underscoring the prevalence of underpayment in initial determinations.
High-impact specialties—such as emergency medicine, radiology, and anesthesiology—are particularly vulnerable, with the scope of the problem growing. According to American Health Insurance Plans (AHIP) and the Blue Cross Blue Shield Association (BCBSA), over 10 million NSA-eligible claims were processed in just the first nine months of 2023. Each missed claim or overlooked deadline represents more than just lost revenue; it sets a precedent for future underpayments.
Leveraging Technology as a Revenue Multiplier
Given the fluid regulatory landscape, hospitals must evolve quickly. Recent court decisions—including the Fifth Circuit’s October 2024 partial reversal of key rulings related to the IDR process and the Qualifying Payment Amount (QPA) methodology—have further complicated the environment. With additional key components of the NSA, such as the Advanced Explanation of Benefits (AEOB) and Continuity of Care provisions, still pending, agility and strategic foresight are now more critical than ever.
For hospital and health system revenue cycle executives, relying solely on compliance isn’t enough. To stay ahead, forward-thinking hospitals are embracing specialized AI-powered automation to streamline the management of OON claims—from identification and tracking to negotiation and resolution.
Five Technology-Driven Strategies for OON Claims Recovery:
- Automate Claim Identification
Artificial intelligence (AI) can be used to surface underpaid claims subject to NSA regulations, enabling revenue cycle teams to focus on the 20% of claims that drive the most revenue. Automation ensures that high-value claims are promptly flagged for review, improving recovery rates and minimizing manual effort. - Track Deadlines with Precision
The 30-day negotiation window following initial payment is critical for successful claims resolution. Automated tracking systems and alerts can ensure that no opportunity is missed. By implementing escalation workflows, hospitals can stay on top of approaching deadlines and avoid locking in suboptimal payment rates. - Customize Payer Playbooks
One-size-fits-all strategies don’t work for every payer. By analyzing payer-specific trends and historical outcomes, hospitals can tailor negotiation tactics to maximize recovery. Data indicates that such tailored strategies can increase IDR success rates up to 70%, providing a measurable advantage in disputes. - Leverage IDR Outcomes Systematically
Winning IDR cases isn’t just about getting paid—it’s about improving future negotiations. Through the power of AI and machine learning, hospitals gain insights into decision outcomes to refine future IDR submissions. This data can also be used to strengthen in-network contract negotiations, further optimizing reimbursement rates. - Make Informed Build-vs-Buy Decisions
Managing OON claims internally requires specialized knowledge and significant resource investment. CRCOs should assess whether external partners, internal teams, or hybrid models offer the best ROI based on their OON volume and available resources. Strategic decisions around outsourcing or partnering can help scale operations without overburdening internal teams.
Looking Ahead: The Evolving NSA Landscape
The regulatory environment surrounding the No Surprises Act remains in flux, with recent court decisions and potential policy shifts under the Trump administration adding layers of complexity. As these developments unfold, CRCOs must stay nimble and adapt quickly to changes in the law, particularly concerning the IDR process and QPA calculations.
As the landscape evolves, hospitals must recognize that success under the NSA will depend less on simple compliance and more on a proactive, strategic approach to OON revenue management. The hospitals best positioned for success are those that take advantage of advanced technology to streamline processes, improve recovery rates, and drive better financial outcomes. Regulatory complexity is a given, but lost revenue is not inevitable.
About Liana Hamilton
Liana Hamilton, Aspirion’s General Manager of Payment Variance Recovery, was most recently CEO and Founder of Boost Healthcare. She has been working with healthcare providers on revenue cycle issues for over 25 years. Prior to founding Boost Healthcare, Liana collaborated with the revenue cycle management teams of well-known names in healthcare, including HCA Healthcare, Tenet Healthcare, Sutter Health, Dignity Health, Ascension, and Trinity Health. Liana has developed and implemented positive change by helping her clients recover millions in lost revenue through her work with the No Surprises Act, Zero-Balance Review, Payment Variance, Payer Contracting, and Denials Management. She values the collaboration that comes with a strong vendor-client relationship.
About Aspirion
Aspirion, a US-based, technology-leading revenue cycle management company, partners with healthcare providers to capture revenue from their most difficult to resolve claims. Leveraging domain expertise, proprietary technology, and artificial intelligence (AI), Aspirion recovers otherwise lost claims revenue by overturning denials and underpayments, resolving aged accounts receivable, and effectively managing complex claims collections, including motor vehicle accident, workers’ compensation, Veterans Affairs and TRICARE, and out-of-state Medicaid. Aspirion’s experienced team of clinical, legal, and technical professionals—combined with industry-leading technology and AI platforms—helps ensure providers receive their earned revenue so that they can focus on patient care. The company serves clients across the US, including 12 of the 15 largest health systems in the country.
