No surprises act & IDR services
An underpaid claim has a funny way of becoming a write-off when nobody bothers to question it.
Out-of-network claims subject to the No Surprises Act are frequently reimbursed at rates that fall far below the actual cost of care. Providers either accept that underpayment or lose the chance to challenge it, since IDR runs on strict timelines, eligibility criteria, and Qualifying Payment Amount estimates. Missing a single deadline can end the right to dispute the payment for good.
MedHeave reviews the reimbursement and opens negotiation with the payer before any deadline closes. When negotiation does not resolve it, we file the IDR submission with full supporting documentation and answer every payer rebuttal using the same QPA data the payer relied on. This process lets providers recover revenue that health plans expected them to write off permanently.
Our operational footprint
These aren't aspirational targets.
These metrics are what we deliver, consistently, across all practices and specialties we work with.
75 to 85%
IDR success rate
70 to 80%
Charges recovered
100%
Deadline compliance
30-day
AR negotiation tracking
A claim can survive a lot. Compliance mistakes are not one of them.
Most providers know the No Surprises Act exists, but far fewer know which claims qualify, when its protections apply, or how the dispute process works. That gap between awareness and execution leaves underpaid out-of-network claims unresolved. The process is governed by strict eligibility rules and filing deadlines, and once those deadlines pass, the opportunity to recover revenue is gone.
Our compliance team at MedHeave begins with a compliance assessment of your billing workflows, payer contracts, network status, and claim history to identify where NSA protections apply. The team validates qualifying claims using payer remark codes such as N830, N813, N858, and N877 before the appropriate compliance and reimbursement workflows begin. It manages Good Faith Estimate requirements for uninsured and self-pay patients, and coordinates Advanced Explanations of Benefits for insured patients when required.
Some billers might call the first payment final because checking what the payer actually paid is apparently too much work.
Revenue loss on out-of-network claims rarely comes from a single mistake. It hides inside reimbursement decisions that go unquestioned, unresolved, or simply accepted as normal. Without a structured dispute process, these recurring workflow gaps leave recoverable revenue behind.
Missed claim identification
Not every underpaid out-of-network claim qualifies for No Surprises Act protections, which makes accurate identification essential. Without a structured screening process, qualifying claims remain buried in remittance files instead of entering the dispute workflow. As a result, recoverable revenue is lost before the process even begins.Â
Expired filing deadlines
Every dispute is governed by strict federal timelines. A provider has 30 business days from the initial payment or denial to start open negotiation. The clock starts on the payment date, not the day someone opens the remittance. Miss that federal window, and the claim can never reach IDR.Â
Weak dispute documentation
A valid claim does not guarantee a successful IDR outcome. Supporting documentation must clearly justify the requested reimbursement through QPA analysis, market benchmarks, payment history, and clinical evidence. Without that foundation, even strong disputes can fail.
Unchecked underpayments
An initial payment should never be accepted at face value. Without comparing it against the Qualifying Payment Amount (QPA) and regional reimbursement benchmarks, providers cannot determine whether the reimbursement reflects the value of the services provided. Underpayments often go unnoticed as a result.
Estimate compliance gaps
Good Faith Estimate requirements apply to every uninsured and self-pay patient. If estimates are inaccurate or delivered outside the required timelines, the practice faces unnecessary compliance risk. Those gaps can lead to patient-provider disputes and regulatory exposure under the No Surprises Act.
Scattered dispute tracking
Managing multiple disputes requires more than spreadsheets and reminders. Without centralized tracking, deadlines overlap, filing statuses become difficult to monitor, and important cases stall before they reach resolution. The larger the dispute volume, the greater the operational risk.
Our services
Payers came to the No Surprises Act table with an army. We made sure providers came with better ammunition.
We deliver No Surprises Act and IDR support through defined operational workflows, not generic compliance packages. Every service aligns with a specific stage of the compliance and dispute lifecycle, with clear procedures, documentation standards, and federal timelines.
Compliance assessments
Every engagement begins with a compliance assessment. Our compliance team reviews provider contracts, billing workflows, and payer mix to identify where the No Surprises Act applies, uncover compliance risks, and strengthen out-of-network billing practices.
Good Faith Estimates
Our billing team prepares itemized Good Faith Estimates for uninsured and self-pay patients. We consolidate services across providers, price them accurately, and deliver each estimate within federal timelines with complete documentation.
Advanced Explanation of Benefits
When required, we coordinate Advanced Explanations of Benefits for insured patients. Our team verifies, documents, and delivers each cost estimate within required timelines to support No Surprises Act compliance.
Notice and consent
We manage notice and consent when patient authorization is required for non-emergency out-of-network care. Our team prepares, delivers, and securely maintains that documentation in line with federal requirements.
Balance billing checks
Our compliance team reviews every qualifying claim before patient billing. We verify compliance with No Surprises Act balance billing rules, helping practices prevent violations before they reach the patient.
Open negotiation
When an eligible out-of-network claim is underpaid, our negotiation specialists initiate open negotiation within the required timeline. Reimbursement analysis, market benchmarks, and supporting documentation strengthen every case.
IDR management
If negotiation fails, our IDR team manages the federal filing from submission through final determination. Every submission includes the required claim details, supporting documentation, and reimbursement rationale.
Documentation support
Our documentation team prepares and organizes everything required for every IDR submission. Those records include medical records, billing data, coding support, and payer correspondence, all of it built to strengthen the provider's position.
Reimbursement analysis
Our analysts evaluate every disputed payment against the Qualifying Payment Amount, historical reimbursements, and regional market data. They also factor in provider experience and case complexity to support fair reimbursement.
Payer disputes
We manage payer disputes involving underpayments, cost-sharing errors, and remittance discrepancies on protected claims. Every case follows a structured workflow with defined review and escalation steps.
Reporting and analytics
Our reporting team tracks every NSA and IDR case through centralized reporting. Practices get visibility into recoveries, dispute outcomes, timelines, compliance gaps, and performance trends to support continuous improvement.
Revenue calculator
There could be a surprising amount of recoverable revenue hiding in the remittance files everyone else stopped reading.
Most providers write off out-of-network underpayments without knowing the total. Enter your claim volume and see what MedHeave’s IDR process can recover for you.
Fill in your details and click Calculate now to see your estimate.
Our specialties
Every specialty has its own billing headaches. We’ve made a career out of knowing which ones hurt the most.
No two specialties approach out-of-network reimbursement the same way. MedHeave configures every No Surprises Act and IDR workflow around specialty-specific payer requirements, documentation standards, and dispute strategies.
Behavioral health
In behavioral health, missing eligibility or session tracking can cost several visits, not just one. We stay ahead of authorization limits, benefit caps, telehealth rules, and co-pay terms so billing stays steady through care.
Podiatry
For podiatry billing, we make sure modifiers like 25 and RT/LT are accurate, services align with global periods and payer edits, and orthotics always meet payer-specific authorization and DME requirements before claims go out.
Urgent care
We handle urgent care billing across walk-ins, diagnostics, and procedures. From there, we track payor coding rules, facility contracts, prior authorizations, and eligibility checks so claims never get delayed, cut, or denied.
Orthopedic
We handle orthopedic billing, making sure procedures get authorized upfront and modifiers like LT/RT and bilateral get applied well. Surgical cases with implants are coded and billed the way payers actually expect for payment.
Cardiology
Cardiology billing often triggers NCCI edit denials, bundling issues, and global period violations when E/M services and procedures are billed together. We manage coding and modifier logic to reduce denials and boost payments.
DME
DME billing is handled by aligning orders, documentation, and delivery timelines with payer rules. We apply HCPCS coding, manage capped rentals, and enforce refill limits so claims are never denied for missing paperwork today.
Pediatrics
In pediatrics, we handle well visits and immunizations, making sure vaccine administration and VFC eligibility are correct. Age-based coding stays accurate as well, so nothing gets missed, underbilled, or delayed at any visit.
Anesthesia
The accuracy of anesthesia billing depends on capturing start and stop times correctly. We ensure precise time capture, apply base units and modifiers, and handle medical direction & concurrency so each unit is billed right.
Don’t see your specialty? We likely work in it.
Experienced across 40+ EHRs. We work natively within your system and never route patient data through third-party tools.
Our process
Our process doesn't start when a dispute is filed. It starts the moment your claim hits the payer's desk.
The IDR process runs on federal timelines that do not flex. Miss a negotiation window, file a day late, or submit without the right documentation and the dispute is over before a certified entity reviews it. MedHeave manages every step so providers never lose a winnable dispute to a procedural error.
Initial payment review
Our experts review the initial payment or denial, compare it against QPA benchmarks and regional reimbursement data. Then, determine whether the claim qualifies for No Surprises Act protections.
 Eligibility screening
We verify plan type, review payer remark codes, and confirm the claim meets No Surprises Act eligibility requirements. Non-qualifying claims are filtered out before the dispute process begins.
Open negotiation
Our team initiates open negotiation within the federal timeline and supports every case with reimbursement analysis, market benchmarks, and documentation to pursue a fair payment before IDR.
IDR filing
If negotiation does not resolve the dispute, we file through the CMS IDR portal within the required deadline. Every eligibility check and supporting document is verified before submission.
Entity selection
We coordinate the selection of a certified IDR entity and prepare the case to move forward. If both parties cannot agree, CMS assigns an entity and the dispute continues without delay.
Evidence submission
Our specialists prepare the provider's offer with medical records, payment history, QPA data, and supporting documentation. Every submission is built to strengthen the reimbursement case.
Case management
While the certified IDR entity reviews the dispute, our IDR team tracks deadlines, monitors progress, and responds quickly to additional documentation requests until a determination is issued.
Payment reconciliation
After the determination, we reconcile the payment, update the provider's account, and document the outcome. Every completed case is reviewed to strengthen future dispute strategies.
We didn't write these case studies to brag.
Okay, maybe a little.
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Why MedHeave
Most providers try to manage IDR with borrowed time and borrowed staff. We show up with a full roster built specifically for the job.
Higher IDR success
Our IDR team wins 75% to 85% of the cases it files. That success comes from strong documentation, QPA analysis, market benchmarks, and case-specific reimbursement strategies, not high filing volume.
Stronger recoveries
Successful IDR determinations recover 70% to 80% of billed charges on average. We measure every recovery against the payer's initial payment, giving practices a clear view of the financial impact.
Deadline compliance
Our team tracks every federal deadline from start to finish. They manage negotiation windows, IDR filing, entity selection, and offer submission through centralized tracking, so no dispute is lost to a missed deadline.
Stronger documentation
Every IDR submission is built to support a favorable determination, not simply meet filing requirements. Our documentation team strengthens each case with medical records, payment history, QPA data, market benchmarks, and reimbursement rationale.
Centralized tracking
Practices often manage disputes across multiple payers and claim types at the same time. We centralize every case, giving teams real-time visibility into deadlines, claim status, filing progress, and payer activity.
Consistent compliance
Compliance should remain consistent across every provider and location. Our compliance team standardizes balance billing checks, Good Faith Estimates, notice and consent, and eligibility screening under one structured workflow.
Regulatory oversight
No Surprises Act regulations continue to evolve, and so do our workflows. Our team monitors CMS guidance, updates internal workflows, and keeps your practice compliant without adding to your administrative workload.
Most practices are trying to run the IDR process on a spreadsheet that is already three deadlines behind.
The No Surprises Act and IDR process reward precision, not good intentions. Without structured workflows, practices repeat the same mistakes across every billing cycle. Those gaps delay disputes, weaken submissions, and leave recoverable revenue behind.
Missed eligibility
Eligibility screening is the first step in every dispute. Without a structured review of payer remark codes and claim details, qualifying claims never enter the No Surprises Act process. Instead, they are written off as routine underpayments.
Missed deadlines
The open negotiation window begins as soon as the payer issues payment or denial. Without centralized deadline tracking, practices miss critical filing windows and lose the opportunity to pursue IDR.
Weak submissions
A legitimate claim still needs a strong case. Without QPA analysis, market benchmarks, payment history, and reimbursement support, practices submit disputes that lack the evidence needed for a favorable determination.
Scattered tracking
Delayed compliance
Good Faith Estimates must be issued before a dispute ever exists. When practices delay compliance, they often discover the gap only after a patient files a complaint, turning a preventable issue into a costly one.
FAQs
Still have questions? Here are the ones providers ask most
Here are a few of the questions that come up most from revenue cycle teams and practice administrators working through what NSA and IDR management actually looks like in operation.
How long does the full IDR process typically take from start to final determination?
The federal IDR process typically takes about 47 business days after Open Negotiation ends. Delays can occur if additional documentation is requested or entity selection takes longer.
Can a provider initiate IDR for multiple claims against the same payer at once?
Yes. Qualifying claims involving the same payer, provider, and similar services can often be filed together. Batch filing reduces costs and streamlines the dispute process.
Who pays the IDR arbitration fees, and what happens if the provider wins?
Both parties pay the CMS administrative fee, while the IDR entity charges a separate processing fee. If the provider wins, the payer is generally responsible for the entity’s fee.
What role does the Qualifying Payment Amount play, and can it be countered?
The QPA is the starting benchmark for IDR decisions, but it is not the only factor. Strong documentation, market data, and reimbursement evidence can support a different payment amount.
Does the NSA apply to out-of-network services rendered at in-network facilities?
Yes. The No Surprises Act protects patients receiving covered services from out-of-network providers at in-network facilities, creating both compliance requirements and an IDR pathway.
What happens if a provider issues an incorrect Good Faith Estimate?
If charges exceed the estimate by $400 or more, the patient may initiate a dispute. The provider must review the case and make any required adjustments under federal rules.
What documentation should practices retain to support IDR disputes?
Practices should keep medical records, claims, EOBs, payment or denial notices, and Open Negotiation correspondence. Maintaining complete records strengthens every IDR submission.
How does the IDR process differ for emergency versus non-emergency services?
Is there a minimum claim value that makes IDR worth pursuing?
There is no fixed minimum, but filing costs should justify the potential recovery. For lower-value claims, batch filing often provides a more cost-effective option.
Those remittance files may be more valuable than they look. We’d like to investigate.
Underpaid out-of-network claims rarely announce themselves. They remain inside a remittance file next to correctly paid claims, flagged with a remark code nobody looked up. We go through that data to find them, checking eligibility, QPA amounts, and filing windows before any of it expires. Call and let us look at yours.
