Since its implementation in 2022, the No Surprises Act (NSA) has transformed how healthcare providers handle out-of-network (OON) claims. We sat down with Liana Hamilton, General Manager of Payment Variance Recovery at Aspirion, to discuss the financial impact of the NSA’s Independent Dispute Resolution (IDR) process and how providers can optimize their recovery efforts.
Q: The IDR process has generated significant attention. What does the data tell us about how it’s actually performing?
Liana Hamilton: The numbers are striking. I was just reading an article published by the Healthcare Financial Management Association that in just two and a half years through 2024, providers have recovered more than $2.2 billion through the IDR process compared to what in-network rates would have paid. What’s particularly interesting is that providers are winning 82% of their cases and initiating 85% of disputes overall.
We’re also seeing that when providers win, the average award is nearly 450% of the qualifying payment amount (QPA)—the benchmark that reflects median in-network rates. Meanwhile, when health plans prevail, payments average only 110% of the QPA. This dramatic difference underscores why it’s so critical for providers to actively engage with this process rather than accepting initial low payments.
Q: Who’s driving the volume in the IDR portal?
Liana Hamilton: The activity is heavily concentrated. In that same HFMA article, it details how five private equity-backed provider groups account for almost 60% of filed disputes. One group is even averaging 770% of the QPA in its awarded amounts. This concentration has helped push total disputes to over 3.3 million in the first three years—far exceeding the U.S. Department of Health and Human Services’ original projection of 22,000 disputes annually.
While the involvement of private equity raises questions, it’s worth noting that smaller providers might struggle to navigate this complex process without that kind of organizational support. These claims require specialized knowledge that falls outside the scope of a typical revenue cycle follow-up representative.
Q: What are the biggest obstacles providers face when trying to recover these payments?
Liana Hamilton: Timing is everything. The first major hurdle is simply identifying NSA claims quickly enough. These claims can be scattered across different payer names that aren’t mapped in your system, and payers use remit codes inconsistently. Many cases only surface when someone notices a high-dollar adjustment—and by then, the 30-day window to initiate negotiations may have passed.
Then there’s the payment collection challenge. Even after winning an IDR case, providers report significant problems actually receiving their money. In 2024, 24% of IDR payments awarded to physician association members either weren’t paid within the required 30-day timeframe or weren’t paid in full. It’s common to make eight different follow-up calls just to secure a check.
Providers also struggle with basic information gaps. They might only have the name of a third-party administrator without knowing which insurance company that TPA represents. This makes it difficult to even initiate the dispute process properly.
Q: How have recent legal developments affected the IDR landscape?
Liana Hamilton: Court decisions have significantly tilted outcomes in favor of providers. Litigation led by groups like the Texas Medical Association resulted in rulings that require arbitrators to consider factors beyond just the QPA when making decisions. Courts have also mandated changes to how payers calculate QPAs in the first place.
More recently, we’re seeing air ambulance companies and other providers going to court to enforce IDR awards they believe they’re owed. On the flip side, major payers like Elevance and Aetna are suing some of the busiest provider groups in the IDR portal, alleging widespread submission of ineligible claims. They’re claiming this bogs down the system and that arbitrators are approving claims that should be dismissed. It’s a real escalation in the legal battles around this process.
Q: What technology and strategies are proving most effective?
Liana Hamilton: Automation is essential. Start by loading NSA-specific remit codes into your system and creating workflow alerts to track every deadline and offer amount. You need to flag these claims early, before initiation windows close.
AI is becoming a game-changer. We’re using it to identify potential NSA claims earlier and generate payer-specific submission letters that pull relevant clinical details directly from chart notes and cost data. This efficiency has allowed us to lower our threshold for pursuing claims. We used to set a $10,000 to $20,000 minimum for IDR cases due to the resources involved, but with AI, we can now pursue much smaller claims efficiently..
Payer-specific strategies are equally critical. Each payer has different processes, and submitting through the wrong channel can invalidate your claim. You need to know which payers tend toward single case agreements versus IDR and tailor your approach accordingly. In hospital environments, we see that 85% of NSA claims are successfully negotiated to single case agreements, but over 50% of the total NSA dollars require escalation to IDR.
Q: What’s your bottom-line advice for hospital revenue cycle leaders?
Liana Hamilton: Don’t leave money on the table. A small volume of out-of-network claims can result in millions of dollars annually, and providers are winning the majority of disputes. This is a clear revenue opportunity if you have the right processes and expertise in place.
Many providers are starting to evaluate whether handling NSA claims internally is worth the investment given the specialized knowledge required, or whether partnering externally or using a hybrid model offers better ROI. The skill set needed really is specialized and different from standard revenue cycle work.
The good news is that the IDR system has adapted to handle the volume—it’s now closing 85% of all filed disputes, up from just 29% in year one. With the right approach, technology, and expertise, providers can turn what initially seemed like a compliance burden into a competitive advantage.
For providers looking to maximize NSA out-of-network revenue recovery, industry-specific expertise and systematic workflows are essential to capturing millions in underpaid claims. Contact Aspirion today to learn how we can help.
