Since the No Surprises Act (NSA) took effect on January 1, 2022, healthcare providers have faced significant revenue cycle challenges while adapting to this complex legislation. While the NSA protects patients from unexpected medical bills, it has created substantial financial and administrative burdens for hospitals and healthcare systems nationwide, with some providers experiencing nearly a 40% decrease in reimbursements since the law took effect.
What Is the No Surprises Act?
The No Surprises Act is federal legislation designed to protect patients from unexpected medical bills that occur when they unknowingly receive care from out-of-network providers. The law establishes billing protections in three key scenarios: emergency services regardless of network status, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers.
Under these protections, patients are only responsible for their in-network cost-sharing amounts—copayments, coinsurance, or deductibles. The legislation also requires good faith estimates for uninsured or self-pay patients, clearer cost information on insurance cards, more accurate provider directories, and price comparison tools.
While the NSA has provided some protection for patients against the most egregious surprise bills, most patients remain unaware of their NSA protections, creating potential satisfaction challenges during registration, financial counseling, and billing processes. These notable awareness gaps, plus inconsistent implementation, still leave many patients vulnerable to unexpected healthcare costs.
Hospitals and healthcare systems need practical strategies to maintain financial health while complying with these regulations. Here are five essential approaches to optimize your out-of-network claims under the NSA:
1. Establish a Dedicated NSA Revenue Team
The NSA has created unique challenges requiring specialized expertise. Forward-thinking organizations are establishing dedicated teams focused specifically on out-of-network NSA claims and disputes. These teams should possess:
- Deep understanding of contract interpretation
- Expert negotiation skills to secure appropriate reimbursement
- Experience with the Independent Dispute Resolution (IDR) process
- Strong financial analysis capabilities
- Ability to effectively manage aggressive timelines within 30-day NSA window
- Knowledge of payer-specific behaviors and tactics
This specialized approach to out-of-network NSA claims segments staff to enable core teams to concentrate on essential day-to-day functions.
2. Implement Purpose-Built Technology Solutions
The 30-day negotiation window for NSA claims creates significant deadline pressures. Purpose-built technology solutions can help by:
- Automatically identifying NSA-eligible claims
- Tracking critical deadlines and documentation requirements
- Streamlining the IDR submission process
- Providing analytics on payer behaviors and successful dispute strategies
These tools reduce the administrative burden while helping to ensure no out-of-network revenue slips through the cracks.
3. Develop Payer-Specific Strategies
Not all payers handle NSA claims the same way. Data from the first half of 2023 showed providers prevailed in 77% of nearly 84,000 IDR decisions, but success rates vary significantly by payer. Strategic organizations should:
- Focus resources on plans with the highest denial rates and lowest initial payments
- Track Qualifying Payment Amount (QPA) trends by payer
- Develop customized negotiation approaches based on payer-specific patterns
- Document successful dispute resolution strategies for future reference
This targeted approach ensures your team allocates its limited resources to the highest revenue recovery opportunities.
4. Leverage IDR Success Data in Network Negotiations
Contrary to initial fears, provider networks have expanded under the NSA, with 67% of plans reporting network growth. This creates a strategic advantage for providers who:
- Document their IDR success metrics by payer
- Use this data as leverage in network contract negotiations
- Highlight payment pattern disparities during renegotiations
- Demonstrate the financial benefits to payers of fair, in-network arrangements
Well-prepared organizations can transform NSA out-of-network compliance from a burden into a strategic advantage during payer negotiations.
5. Redesign Patient Financial Communications
HHS research reveals most patients remain unaware of their NSA protections, creating potential satisfaction challenges during registration, financial counseling, and billing. Effective providers are:
- Training patient access staff on clear NSA explanations
- Developing simple educational materials for affected patients
- Redesigning billing statements to clearly identify NSA protections
- Creating streamlined processes for handling NSA-related patient questions
These communication improvements not only ensure compliance but also enhance the overall patient financial experience.
Next Steps for Providers
The NSA represents both a significant challenge and a timely opportunity to reimagine financial operations in today’s patient-centered healthcare environment. The organizations that will thrive are those implementing targeted strategies that not only mitigate revenue disruption but leverage the new regulatory environment for financial advantage.
Providers need immediate strategies to protect their financial health under the NSA, yet many hospitals lack the specialized resources and technology to implement these strategies effectively. As the No Surprises Act continues to evolve through legal challenges and legislative updates, hospitals and healthcare systems should consider tackling the issues with advanced AI technology along with a dedicated team of experts.
Ready to discover how Aspirion can help you recoup revenue from your out-of-network NSA claims. Let’s talk, contact us today!
