Navigating financial challenges of the No Surprises Act

When the No Surprises Act (NSA) took effect in 2022, it did more than protect patients from unexpected bills. It fundamentally reshaped medical billing for the industry.

Early results suggest it has succeeded for patients. Before the NSA, 16% of in-network hospital stays for individuals with large employer coverage included at least one out-of-network charge.¹ The passage of the NSA changed this dynamic, shielding patients from those unexpected bills. For large emergency medicine billing organizations, however, the story is more complicated.

The NSA’s independent dispute resolution (IDR) process gives providers a formal mechanism to contest out-of-network reimbursement in certain circumstances. However, demand has far exceeded expectations as uptake has been nearly 70 times the federal projections.² This makes it clear that the NSA has shifted the burden of cost reconciliation to providers, turning IDR into an ongoing financial consideration rather than a one-time compliance exercise.

Understanding QPA and the new dispute landscape

At the heart of NSA economics lies the Qualifying Payment Amount (QPA), which is generally based on the median contracted in-network rate for a given service in a specific region. It’s the benchmark for patient cost-sharing and a key reference point in IDR disputes.

Payers often anchor their initial out-of-network offers around the QPA, which leads to lower reimbursement rates. Given the increased process complexity introduced by the NSA, organizations are often more likely to accept this offer rather than take on the additional administrative burden, cost, and risk to recoup what they’re owed.

At least one analysis shows that in healthcare IDR disputes, providers who successfully navigate IDR win 85% of the time, frequently resulting in final payment determinations that are several times higher than the QPA.³ For large emergency medical billing organizations handling millions of claims each year, the burden of IDR participation has become table stakes.

Reassessing IDR through the lens of athenaIDX

Given the success rate of providers in IDR disputes, why don’t more participate in that process? For many organizations, the upfront costs seem too prohibitive. Training enough staff to manage, track, and dispute potentially thousands of resolutions within a regionally varying and complex system is daunting enough. Add to that, the potential for backlogs, processing delays, the potential for manual entry errors, and the initial IDR filing fee for each dispute (that ranges from $200-$840 for single disputes, and $268-$1,173 for batched disputes4), and the choice to avoid disputes is easier to understand.

This is where the value of investing in an RCM solution like athenaIDX becomes clear. The flexible workflow automation within athenaIDX is specifically designed to handle complex workflows like dispute management at scale. They provide comprehensive support that relieves manual burden and helps improve accuracy and the potential for success through automation.

New challenges require new operating models

Leveraging the IDR process to recover proper reimbursement costs without automation is completely impractical at the enterprise level. The volume of patients and variety of care requires a platform with systematic approaches that:

• Identify viable IDR opportunities across millions of emergency medicine claims
• Batch claims strategically to optimize IDR filing fee economics against expected recovery
• Track dispute status and outcomes to maximize payment reconciliation
• Provide payer behavior analysis to predict which cases warrant IDR investment

Manual processes that might have worked for smaller dispute volumes break down entirely at this scale and complexity. Here are three areas where an RCM solution like athenaIDX can help support and drive strong returns for larger volumes of IDR cases.

1. Automate dispute management 

• Automate data entry across the IDR workflow to reduce processing costs and protect regulatory timelines
• Smart batching algorithms prioritize opportunities with the highest potential impact to A/R and optimize filing fee economics
• Integrated workflow management tracks each case from negotiation through payment determination

A solution like athenaIDX automates data entry and submission workflows, identifies high-risk recovery opportunities, and tracks the process from end-to-end. This allows organizations to support scalable healthcare dispute management without overwhelming existing teams. 

2. Real-time performance visibility 

• Dispute analytics that reveal which payer and case types yield the best IDR outcomes
• Recovery tracking that measures actual IDR results against initial payer offers
• Performance analysis that guides future IDR strategy and resource allocation

athenaIDX's healthcare dispute analytics help organizations identify where outcomes are likely to be strongest and quantify recoverable revenue across payer and case types. 

3. Scalable compliance and documentation 

• Audit ready documentation that supports IDR determinations and protects revenue recovery
• Regulatory timeline management that helps prevent missed deadlines and forfeited opportunities

Intelligent task updates and agentic workflows within athenaIDX help teams stay ahead of IDR timelines while maintaining rigorousIDR records through detailed dispute tracking. Comprehensive dispute histories provide the documentation needed to demonstrate compliance and support successful dispute outcomes. 

From compliance burden to strategic advantage 

The No Surprises Act represents a fundamental shift in emergency medicine economics. Success now requires that healthcare organizations have the tools to enable them to claim what they’re owed, or struggle with increased manual burden and potentially accept reduced reimbursement for the care they provide. 

Navigating the complexities and burdens of the dispute process presents a significant challenge for many organizations. However, solutions like athenaIDX can help organizations manage the process efficiently and at scale.