5 Tech-Driven Strategies to Capture Your Out-of-Network Revenue Under the No Surprises Act – Becker’s Hospital Review

Since the implementation of the No Surprise Act (NSA) in January 2022, the out-of-network (OON) reimbursement has become a complex and resource-baron challenge for the hospital and health system revenue cycle leaders. Although unexpected medical bills are designed to mold patients, the law has continuously put financial pressure on hospitals and health systems, causing payment, operational burden and stressful resources.

Controversy backlog: delayed payment, increasing frustration

According to FTI consultation, between April 2022 and June 2023, the providers presented more than 490,000 disputes under the NSA with 61% unresolved. For the officials of the revenue cycle, it not only represents delayed payment, but also represents significant disruption in cash flow, challenges, and additional stress already on overburdan teams.

However, there is a silver lining: the providers are winning most disputes. Data from the US Department of Health and Human Services (HHS) suggests that the provider of about 84,000 independent dispute resolve (IDR) cases in the first half of 2023 became stronger in 77%, underlining the prevalence of the underestimation in initial fixation.

High-effect specifics-as emergency medical, radiology and anesthesiology are particularly weak, with the scope of the problem. According to the American Health Insurance Plan (AIP) and the Blue Cross Blue Shield Association (BCBSA), more than 10 million NSA-eligible claims were processed in the first nine months of 2023. Each left claim or unseen deadline represents more than only lost revenue; It sets an example for future underpapers.

Take advantage of technology as a revenue multiplier

Given the fluid regulatory landscape, hospitals should develop quickly. The recent court verdict- The environment has been further complicated by partially reversing the fifth circuit of major rulings related to the IDR process and the qualifying payment amount (QPA) method. With additional major components of NSA, such as advanced explanation of benefits (AEOB) and continuity of care provisions, still pending, agility and strategic foresight are now more important than ever.

It is not enough for the officers of the revenue cycle for hospital and health system, to rely on full compliance. To stay ahead, the forward-screening hospital is embracing special AI-operated automation to streamline the management of the claims-from corresponding to dialogue and resolution.

Five technology-governed strategies for OON claim collection:

1. Automated claim identification
   Artificial Intelligence (AI) can be used for the surface under the NSA rules, which can enable the revenue cycle teams to focus on 20% claims that increase the most revenue. The automation ensures that high-value claims are immediately approved for review, improve recovery rates and reduce manual efforts.
2. Track the time limit with accuracy
   The 30-day dialogue window is important for the solution of successful claims after initial payment. Automatic tracking systems and alerts can ensure that no opportunity is missed. By implementing the escalation workflows, hospitals can stay at the top to get closer to the deadline and avoid locking in subptimal payment rates.
3. Customize the pair playbook
   A size-fit-all strategies do not work for every payment. By analyzing the payment-specific trends and historical results, you can tailor the interaction strategy to maximize hospital recovery. The data indicates that such an analog strategies can increase the IDR success rate by 70%, leading to an average benefit in disputes.
4. Leverage IDR results systematically
   Winning IDR cases is not just about paying – this is about improvement in future interactions. Through the power of AI and machine learning, hospitals achieve insight into decisions to refine future IDR submissions. This data can also be used to strengthen in-network contract dialogue, allowing reimbursement rates to be further adapted.
5. Informed Build-Bann-Kharid Decide
   The management of Oon claims requires internal special knowledge and important resource investment. CRCOS should assess whether external partners, internal team, or hybrid models provide the best ROI based on their Oon volume and available resources. Strategic decisions around outsourcing or participation can help internal teams operate the scale without overbird.

Looking forward: Developed NSA scenario

The regulatory environment around the No Surprise Act remains in the flow, adding layers of complexity under the Trump administration in recent court decisions and potential policy. As these developments come to light, CRCO should remain agile and be quick to change the law, especially about the IDR process and QPA calculations.

As the landscape develops, hospitals will have to identify that success under NSA will depend less on simple compliance and more on an active, strategic approach to on revenue management. The best deployed hospitals for success are those who take advantage of advanced technology to streamline procedures, improve recovery rates and run better financial results. Regulatory complexity is one given, but lost revenue is not unavoidable.

About Liana Hamilton

Leena Hamilton was the General Manager of Aspirian of Payment Variation Recovery, recently CEO and founder of Boost Healthcare. She has been working with healthcare providers on revenue cycle issues for 25 years. Prior to the establishment of Boost Healthcare, Liana collaborated with the revenue cycle management teams of famous names in Healthcare, including HCA Healthcare, Tetnet Healthcare, Sutter Health, Dignity Health, Escation and Trinity Health. Liana has developed positive changes to her customers by helping their customers to recover millions in lost revenue through their work with their customers, zero-equilibrium reviews, payments contracts, and refusal management. She gives importance to the cooperation that comes with a strong seller-grabbing relationship.

About aspiration

Aspirion, a US-based, technology-agron revenue cycle management company, to resolve claims with partners with healthcare providers to capture their most difficult from the most difficult revenue. Leveraging domain expertise, proprietary technology, and artificial intelligence (AI), aspirion lost revenue to refusal and turning down the underaments, receiving old accounts, and effectively managing collections of complex claims, motor vehicle accidents, compensation of workers, legendary cases and tricks and out-status. Experienced team-industry-technology and AI platforms of aspirion of clinical, legal and technical professionals jointly ensure that the providers receive their earned revenue so that they can focus on the patient’s care. The company serves customers across the US, including 12 of the 15 largest health systems in the country.