How hospital leaders can shift from compliance to strategy—and capture millions in reimbursements
Since the No Surprises Act (NSA) took effect in January 2022, hospital revenue cycle leaders have faced a steady stream of operational and financial headaches working complex out-of-network claims under tight timelines. They are finding that non-contracted payers often reimburse well below commercial and even Medicaid rates, and their inconsistent use of NSA-specific remit codes makes timely identification challenging. Many organizations also still lack the automation, tracking tools, and payer-specific workflows to spot these claims quickly enough, allowing valuable reimbursement to slip away.
However, Liana Hamilton, general manager of payment variance recovery for Aspirion, says the right approach can turn this situation from a legislative burden into a competitive advantage. “A small volume of out-of-network claims can result in millions of dollars a year, and providers are winning a majority of disputes,” she notes.
In this conversation, Hamilton, who works closely with hospitals and health systems, shares how they can avoid leaving money on the table, move to a proactive strategy, and implement the processes, technology, and payer strategies that make out-of-network revenue recovery both achievable and worth the effort.
Q: How has the No Surprises Act fundamentally changed the out-of-network claims landscape?
Hamilton: The NSA was designed to protect patients from large surprise bills, but it’s also created a loophole for non-contracted payers to reimburse far below customary commercial rates. We’re seeing payments of 10% to 15% of billed charges—well under contracted commercial payer levels of 50% to 80% and even below what Medicaid pays, which is unacceptable.
This environment reduces the incentive for payers to contract with providers. Without a system to identify and contest low payments, hospitals risk locking in subpar rates. Many of these cases originate in the emergency department, where the patient’s insurance is not contracted with the hospital or health system. We also see a lot of these large marketplace or exchange plans that have picked up significant volume nationally but aren’t contracted with providers. For larger cases, single-case agreements may be negotiated while the patient is in-house, but most are not. Once the payment posts, the 30-day clock starts ticking. Complacency here can result in significant lost revenue and lower benchmarks for future reimbursement.
Q: What are the most significant operational and financial challenges revenue cycle teams struggle with most day to day?
Hamilton: The first hurdle is simply identifying these claims on time. They can be spread out across payer names that are not mapped in the system. Payers’ inconsistent use of remit codes tied to the No Surprises Act also makes automation difficult. 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.
Secondly, hospitals are managing multiple timelines. They must initiate a single case agreement within the 30-day window, then if an agreement is not reached and they escalate to the independent dispute resolution (IDR) process, they must meet another set of requirements. Even after a favorable outcome, there’s the challenge of getting paid. It’s common to see eight different follow-up calls to secure a check. The good news is that there are numerous revenue opportunities. Through the IDR process, we’re overwhelmingly seeing that initial payments are too low, which creates clear opportunities to recover more.
Q: What strategies and technologies are proving most effective for hospitals trying to stay ahead of this evolving regulatory landscape?
Hamilton: Start by automating wherever possible, including identifying payer classes and loading remit codes specific to the NSA, so that claims can be flagged early. Build workflow alerts to track every deadline to ensure payment and avoid accepting lower rates. Payer strategies are equally critical. Customize playbooks for your top payers. Each has different processes, and the wrong submission route can invalidate a claim. Know who tends toward single case agreements versus IDR, and tailor your approach accordingly. In the hospital environment we see that 85% of the NSA claims are successfully negotiated to a single case agreement but over 50% of the NSA dollars require escalation to the IDR.
Staff training is also essential. These aren’t typical follow-up claims—they require negotiators with knowledge of both revenue cycle and managed care contracting. Train teams to recognize acceptable payment thresholds and escalate when offers fall short. The most advanced providers have their qualified payment amount that is approved and programmed in the EHR.
AI is also changing the game. We use it to flag potential No Surprises Act claims earlier and generate payer-specific submission letters with relevant clinical details pulled directly from chart notes and cost data. That efficiency lets us pursue smaller-dollar claims we might have once skipped. Our clients have been really excited about that, too, because every dollar counts. For example, with one health system partner Aspirion used to set a $10,000 to $20,000 threshold for IDR due to the time and resources involved. With AI, we’ve been able to lower that amount significantly, making smaller claims worth pursuing.
Q: What is your final advice for hospital leaders on NSA out-of-network revenue recovery?
Hamilton: Treat this as a revenue opportunity worth the investment. The data shows that even small claims volumes can translate into millions annually when worked correctly. Providers who've been in this from the beginning are also starting to evaluate whether it’s worth doing it internally—because of the specialized knowledge and significant investment required—or if an external partner or hybrid model will offer the best ROI. The skill set is specialized and falls outside of the scope of a typical revenue cycle team follow-up representative. Some providers are recognizing that it may not be worth doing entirely on their own.
Ultimately, having all these processes in place will help you identify early on when a new payer or a non-contracted payer’s volume is growing and give you the opportunity to engage in contract negotiations proactively. No one wants to navigate this process unnecessarily, but even a few half million dollar claims can be worth the effort and set expectations for future rates.