January 1, 2022: The Day Out-of-Network Billing Changed Forever 

2022 was a landmark year in the history of U.S. healthcare. A host of changes swept across America. Wage inflation hit 15 to 30% for a large number of clinical and non-clinical roles; CMS (Centers for Medicare & Medicaid Services) started actively enforcing price-transparency rules, especially for hospitals; Telehealth was finally normalized and stopped being an ‘emergency-only’ measure; and payers, providers, patients, and RCM teams woke up to the reality of the No Surprises Act (NSA) which protected patients from the menace of balance bills, especially after an out-of-network encounter. 

The NSA came into effect on January 1 the same year. And with it, the Independent Dispute Resolution (IDR) became operational. It changed the entire dynamics of out-of-network (OON) billing, deeply impacting the OON reimbursement reality for specialties like emergency medicine, anesthesiology, cardiology, radiology, air ambulance, and a host of other hospital-based specialties. 

Out-of-Network Collections: The Present Picture (and the Hidden Truth) 

We have come a long way since then. 

Arbitrations from the IDR process have led to the collection of billions in revenue by providers. According to a report, the figure touched $2.2 billion in 2024 alone. There has also been a growing predominance of providers in IDR settlements, with their claims winning in about 80% cases. 

All of the above may paint a rosy picture to most. But the truth is a little different. 

Ever since the onus of settling out-of-network disputes fell on the shoulders of payers and providers alike, with CMS-appointed IDRe’s (Independent Dispute Resolution Entities) finally arbitrating and choosing one party’s offer over the other’s, everyone is treading with caution. 

Providers are trying their best to refute the payer’s offers which, being based on the regular, in-network rates are usually much lower than the amounts billed by the provider. 

Payers, on the other hand, stubbornly cling to their offers the QPA (Qualifying Payment Amount) taking every opportunity to prove that the provider’s expectations are unjustified, erroneous, or simply bloated. 

There is a constant tussle, and the state of affairs is not an easy one, to say the least. 

Entering the NSA-IDR Arena: The Roadmap for RCM Companies 

It is evident that given the cautious stances adopted by the parties, along with the complex provisions of the No Surprises Act and the increased importance of supporting documentation to build compelling arguments regular RCM personnel rarely manage to do justice to OON settlements. It’s a completely new battle, and requires a different mindset and a different set of weapons to win. 

This is where a partner who is solely focused on NSA-IDR, and is well-versed in the rules that govern it, becomes a valuable asset to providers struggling with underpaid (or even, unpaid) OON claims. This is a fact that RCM companies too are realizing in rapid numbers. Years of experience in in-network billing do not help much here. The need of the hour is specialized expertise, specially-trained personnel, workflows streamlined to deal with out-of-network claims efficiently, and a good deal of legal acumen, too. 

And these are the things that the typical RCM outfit frequently lacks. 

Taking the Leap into OON Universe: What You Need to Know 

One can, of course, start building such a team from scratch, upgrading operations step by step and doing fresh hires from the ground up. In a practical scenario, however, this will prove to be time-consuming, costly, and not very easy to accomplish (NSA-IDR being a relatively new phenomenon, the market still has very few people who really understand it well or can deliver the results consistently). 

It’s little wonder that we at CollectionPro have been witnessing a steady influx of RCM organizations, knocking at our doors for a partnership. And we have been happily obliging them. Their problems are common a steady flow of OON cases is coming to them but in the absence of the right personnel and skill-set, they have to forgo those lucrative offers. 

Out-of-network claims are high-stake, high-value claims. The payout is much larger than the average in-network bill. RCM organizations everywhere are naturally interested in having a piece of the pie. But without the right skills and resources, this becomes difficult to achieve. Partnering with an RCM organization that knows and understands the ins and outs of out-of-network billing, IDR arbitrations, and balance billing laws both at the state and the federal levels is the best strategy to get started.