Out-of-Network Claims Transformation: Capitalizing on Unforeseen Billing Opportunities under the No Surprises Act

In the ever-evolving landscape of healthcare, the implementation of the No Surprises Act (NSA) has brought about significant changes, particularly in the realm of out-of-network revenue recovery.

Under the NSA, non-contracted payers have been reimbursing far below customary commercial rates, often as low as 10% to 15% of billed charges. This has led to a critical operational challenge for providers, as the lack of a system to identify and contest low payments can result in hospitals locking in subpar rates.

To address this issue, providers are evaluating various strategies. Some are considering handling NSA out-of-network revenue recovery internally, while others are turning to external partners or adopting hybrid models. However, the specialized knowledge and significant investment required for NSA out-of-network revenue recovery may make it unworthy for providers to handle entirely on their own.

Workflow alerts are being implemented to track deadlines and ensure payment, avoiding acceptance of lower rates. Early identification of growing payer or non-contracted payer volumes allows for proactive engagement in contract negotiations.

AI is playing a pivotal role in this transformation. It is enabling the pursuit of smaller claims that were previously skipped and is used to flag potential No Surprises Act claims earlier. AI-generated payer-specific submission letters also streamline the process, making it more efficient.

However, payers' inconsistent use of remit codes tied to the No Surprises Act makes automation challenging. Automation of payer class identification and loading of NSA-specific remit codes is proving beneficial for early claim flagging.

Identifying these claims on time is crucial, as many cases only surface at the leadership levels for a high-dollar adjustment when it is too late to recover payment because the deadline has passed.

Customized playbooks are being developed for top payers, considering their unique processes. Training of staff on revenue cycle and managed care contracting is essential for effective negotiation.

The No Surprises Act has also brought about changes in billing practices. Organizations such as Mass General Brigham and the Richard A. and Susan F. Smith Center for Outcomes Research at Beth Israel Deaconess Medical Center have successfully implemented the effects of the No Surprises Act on out-of-network claims, demonstrating significant reductions in patient out-of-pocket costs since the law's implementation on January 1, 2022.

However, the Independent Dispute Resolution process, a part of the compliance efforts, has led to increased administrative costs. This process has been notably utilized by providers, especially those backed by private equity, to navigate payments for out-of-network claims.

Complacency in dealing with these claims can result in significant lost revenue and lower benchmarks for future reimbursement. Therefore, it is essential for providers to stay vigilant and proactive in their approach to out-of-network revenue recovery under the No Surprises Act.