A long-awaited rule overhauling the federal Independent Dispute Resolution (IDR) process established under the No Surprises Act (NSA)—the landmark consumer protection law designed to shield patients from unexpected out-of-network medical bills—was finalized last week. The rule, available here, introduces a redesigned portal, standardized communication requirements, formalized negotiation timelines, and expanded economic access to arbitration.
We sat down with Aspirion’s Liana Hamilton, President of Payment Variance Recovery, and Nikki Ritchson, Senior Director, Payment Variance, to get their analysis of what the rule does, what it means for out-of-network recovery strategy, and what hospital revenue cycle teams should be doing right now.
Q. Give us the headline—what did this rule do?
Liana Hamilton: At a high level, this rule restructures how the federal IDR process operates—and from where we sit, working every day with hospital and health system partners on out-of-network recovery, we view it as a net positive. The new framework redesigns the portal into a single, unified system with clear and trackable timelines, codifies federal IDR eligibility criteria, and introduces real payer accountability for timely payment following IDR determinations. These aren’t cosmetic changes. They address genuine friction points that have slowed resolution and created unnecessary ambiguity for providers.
Q. Payers have been vocal about what they say the rule didn’t do. How should revenue cycle leaders interpret those complaints?
Liana Hamilton: Payers wanted this rule to impose much tighter constraints on the arbitration process itself—things like auditing arbiters, creating new oversight mechanisms, and penalizing arbiters who consistently award rates above in-network levels. The fact that this rule didn’t go there is meaningful. It signals that regulators recognized what Aspirion sees every day: that providers have been systematically underpaid, and that high provider win rates in IDR reflect that reality, not abuse of the system. Our own experience with hospital partners has been consistent—IDR determinations have not exceeded average commercial rates, but initial payer payments have been substantially below Qualifying Payment Amount expectations with near uniformity. That is the data behind the win rates payers find inconvenient.
Q. One of the most significant operational changes involves CARC and RARC codes. Why should revenue cycle leaders pay attention to this?
Nikki Ritchson: This is one of the most practically important pieces of the rule. Going forward, payers will be required to use the standardized Claim Adjustment Reason Code (CARC) and Remittance Advice Remark Code (RARC) associated with the NSA. For revenue cycle teams, that standardization is a genuine tool—it gives providers the transparency needed to accurately assess claim eligibility and dispute viability. Historically, inconsistent remittance information made it difficult to determine quickly whether a claim belonged in the federal IDR process or under an applicable state process. That distinction is foundational to a sound out-of-network recovery workflow, and cleaner remittance data will make getting it right faster and more reliable.
Q. You mentioned the federal versus state IDR distinction. Why does that matter so much?
Nikki Ritchson: It cannot be overstated. The efficiencies created by this new portal do not extend to state-governed claims—and in fact, the portal will actively reject claims that belong in a state process. For any organization working out-of-network recovery, that determination is not a downstream step; it is the first step. At Aspirion, evaluating whether each claim falls under the federal or applicable state IDR process is a foundational part of our workflow. The new rule improves the federal pathway considerably, but state-governed claims remain subject to their own—often less efficient—processes. Revenue cycle leaders who assume this rule applies universally to all out-of-network disputes will make costly errors.
Q. The rule also cuts administrative filing fees and allows claims to be bundled by patient. What’s the practical impact?
Nikki Ritchson: Both changes meaningfully expand the economic case for pursuing disputes. Lower filing fees reduce the threshold at which a dispute becomes worth the investment—which opens up recovery on accounts that previously would have been left behind. The bundling provision is equally significant: the ability to group claims by patient ensures that all providers involved in an episode of care can be considered together, including those whose individual underpayment amounts wouldn’t have independently cleared prior submission thresholds. For hospitals managing high volumes of out-of-network accounts, that changes the math on a meaningful segment of inventory.
Q. What should revenue cycle leaders be doing right now?
Liana Hamilton: Three things. First, make sure your team understands the updated eligibility criteria and how the new open negotiation requirements work—initiating parties must now submit a notice with supporting documentation to both the opposing party and the Departments, and a response is required from the receiving party. The formalized process creates more structure, and teams that aren’t aligned to it will experience avoidable delays. Second, treat the new CARC/RARC requirements as an opportunity. Use those codes as a trigger for eligibility review and to accelerate the federal vs. state determination that should be driving every dispute decision. Third, take a hard look at accounts you may have previously set aside because the economics didn’t pencil out. Between lower filing fees and the new bundling capabilities, some of those accounts are worth revisiting.
The broader message is this: this rule strengthens the out-of-network recovery environment for providers. Don’t sit on the sidelines while payers continue to contest its implications.
The No Surprises Act landscape continues to evolve, and staying ahead of it requires both deep expertise and workflows built for precision. Aspirion’s out-of-network recovery team helps hospital and health system partners capture the reimbursement they’ve earned—navigating federal and state IDR processes with the rigor that complex claims demand. Reach out to our team to learn how we can put that expertise to work for your hospital or health system.
