Published in Becker’s Hospital Review, April 2025 | Author: Liana Hamilton, General Manager, Payment Variance Recovery, Aspirion
The No Surprises Act (NSA), implemented in January 2022, has placed significant operational and financial strain on hospitals, complicating out-of-network (OON) reimbursements. Between April 2022 and June 2023, over 490,000 disputes were filed under the NSA, yet 61% remain unresolved, creating cash flow disruptions and additional stress on revenue cycle teams. Despite the challenges, providers are prevailing in IDR disputes 77% of the time, highlighting widespread underpayment issues, particularly in high-impact specialties like emergency medicine and anesthesiology.
The evolving regulatory landscape demands proactive strategies. Advanced court rulings and pending provisions, such as the Advanced Explanation of Benefits (AEOB), make agility essential for staying ahead. Forward-thinking hospitals are achieving this through AI-powered automation and customized strategies for OON claims recovery.
The five key technology-driven strategies include:
- Automating Claim Identification: AI ensures that high-value, underpaid claims are flagged, enabling teams to focus on impactful disputes.
- Precise Deadline Tracking: Automation prevents missed opportunities by alerting teams about critical deadlines within the 30-day negotiation window.
- Customizing Payer Playbooks: Tailoring approaches to payer-specific patterns can increase success rates in IDR disputes by up to 70%.
- Leveraging IDR Outcomes: Using AI-driven insights from past disputes refines future strategies, enhancing recovery and even improving in-network contract negotiations.
- Making Strategic Build-vs-Buy Decisions: Hospitals must weigh the benefits of outsourcing versus internal management to balance resources and optimize ROI.
Success under the NSA hinges on using advanced technology to streamline operations and tackle reimbursement complexities. While regulatory challenges are inevitable, lost revenue doesn’t have to be. A proactive and tech-savvy approach positions hospitals to thrive under the NSA and beyond.
Read full Becker’s Healthcare article here.