No Surprises Act Compliant
Out-of-Network Billing That Protects Your Revenue
& Your Compliance
OON billing is the most complex, and highest-stakes, billing in healthcare. ProvidaRCM maximizes your out-of-network reimbursements through payer negotiation, Single Case Agreements, and IDR while keeping you fully compliant with the No Surprises Act.
- HIPAA Compliant
- AAPC Certified
- No Long-Term Contracts
- All 50 US States
OON Billing Reality
2X
Average OON Reimbursement vs. In-Network
Out-of-network providers can receive 150–300% of Medicare rates, but only if claims are billed, negotiated, and appealed correctly.
60%
Of OON Claims Are Underpaid Without Advocacy
Payers systematically underpay OON claims. Without active negotiation and appeals, most OON providers collect far less than they're entitled to.
$10K+
Average Recovery Per IDR Arbitration Win
ProvidaRCM has managed hundreds of IDR submissions with a strong win rate, recovering revenue that in-network providers would never see.
The OON Billing Opportunity
Most Practices Miss
Out-of-network billing is complex, but for the right practices, it represents significantly higher reimbursements. The key is doing it correctly, compliantly, and aggressively.
What Is OON Billing?
When you treat a patient whose insurance doesn't have a contract with your practice, you're billing out-of-network.
Without a negotiated contract, there's no predetermined rate. That means higher potential reimbursement, but also more complexity, more denials, and more compliance obligations. ProvidaRCM navigates all of it.
- No pre-negotiated fee schedule, you submit charges and negotiate reimbursement
- Payers process OON claims at their internally-determined "allowable" amount, often 50–80% of billed charges
- Patients may have separate OON deductibles and higher cost-sharing under their plan
- The No Surprises Act (effective Jan 2022) changed the rules, balance billing protections now apply in many circumstances
Average OON Reimbursement
240%
Of Medicare rates, average achieved by ProvidaRCM clients through negotiation and IDR.
Higher Revenue Per Claim
OON reimbursements can be 2–3× higher than in-network rates for the same service. The upside is real, if you pursue it correctly.
Complex Compliance Rules
The No Surprises Act, state balance billing laws, and ERISA plan rules create a complex web of compliance obligations for OON providers.
No Setup Fees. No Surprises.
We charge a percentage of monthly collections only. You pay nothing until we collect, which means our financial success is tied directly to yours.
Who Benefits Most From OON Billing
High-Value Specialty Practices
OON billing is most powerful for specialty practices where in-network rates significantly undervalue services, and where patients actively seek the provider regardless of network status.
- Surgical specialists (orthopedics, neurosurgery, cardiovascular)
- Behavioral health and addiction medicine providers
- High-demand subspecialties with long in-network wait times
- Anesthesiology and emergency medicine groups
- Practices with strong reputation and patient referral base
The Risk Without Expert Management
What Goes Wrong Without ProvidaRCM
OON billing handled incorrectly exposes your practice to serious financial and legal risk. Here's what happens without expert management:
- NSA violations, up to $10,000 per violation in federal penalties
- Systematic underpayment by payers, 40–60% below entitled rates
- IDR deadlines missed, disputes closed in payer's favor automatically
- State balance billing law violations, additional fines and complaints
- GFE non-compliance, patient billing disputes and regulatory action
No Surprises Act:
What Changed
Effective January 1, 2022, the No Surprises Act fundamentally changed how OON billing works. ProvidaRCM ensures your practice is 100% compliant, while still protecting your revenue.
Good Faith Estimates (GFE)
Required for uninsured and self-pay patients before scheduled services. Must include expected charges from all providers involved in care. ProvidaRCM prepares all GFEs correctly.
Advanced EOB (AEOB)
Insurers must provide patients with an estimated cost breakdown before services for scheduled OON care. We ensure your practice provides all required notices.
Balance Billing Protections
Patients in emergency situations and at in-network facilities cannot be balance billed for OON services in most circumstances. We keep you compliant with these restrictions.
IDR Process
When payers and providers disagree on OON reimbursement, the Independent Dispute Resolution process is the legally mandated path. We manage every step of your IDR submissions.
Consent Requirements
In limited circumstances, patients can waive balance billing protections with written consent. We handle proper consent documentation when applicable.
How We Keep You
Compliant & Profitable
Full NSA compliance doesn't mean accepting lower payments. It means navigating the rules expertly to protect both your revenue and your practice from penalties.
1
Eligibility Assessment
Before each encounter, we determine which NSA protections apply, emergency vs. scheduled care, facility type, patient consent, so billing is handled correctly from day one.
2
GFE Preparation
We prepare compliant Good Faith Estimates for all required patients within the mandated timeframes, including all relevant providers' expected charges.
3
Notice & Consent Management
When patients are eligible to waive balance billing protections, we manage the required notice and consent process with properly documented patient agreements.
4
OON Claim Submission & Negotiation
Claims are submitted with all required documentation and immediately tracked. Underpaid claims are escalated for direct payer negotiation and, when necessary, IDR submission.
5
IDR Management & Follow-Through
We prepare and submit complete IDR packages, respond to arbitrator requests, and track every open dispute to resolution, maximizing your IDR win rate.
NSA Violation Penalties
Up to $10,000 per violation for sending a prohibited balance bill
Complaint investigation by CMS with potential corrective action plan
State regulators may impose additional fines under state balance billing laws
Patient complaints can trigger federal audit of your entire OON billing practices
Our Complete OON
Billing Services
From initial claim submission and payer negotiation to IDR management and state compliance, ProvidaRCM handles the full OON billing lifecycle with expertise no in-house team can match.
OON Claim Submission & Tracking
We submit OON claims with all required documentation, ensuring correct coding, proper reimbursement benchmarks, and full compliance from the initial submission.
- Claim submission with Medicare benchmark documentation
- Real-time claim status tracking with payer follow-up
- Underpayment identification against expected reimbursement
- Self-funded ERISA plan claim routing and follow-up
Single Case Agreements (SCA)
Full CAQH ProView profile setup, completion, and ongoing attestation management. CAQH is required by nearly all commercial payers and must be attested quarterly, we manage it so you never lapse.
- SCA identification, which cases warrant negotiation
- Payer outreach and rate negotiation before service
- Contract language review and approval process
- Post-service billing under the agreed SCA rate
IDR Process Management
When payer reimbursement is below the qualifying payment amount, we manage the full Independent Dispute Resolution process, preparing submissions that maximize your arbitration win rate.
- IDR eligibility assessment for each underpaid claim
- Federal IDR portal submission within required deadlines
- Qualified Payment Amount (QPA) analysis and challenge
- Arbitrator communication and outcome tracking
NSA Compliance Management
Full compliance with the No Surprises Act, Good Faith Estimates, notice and consent documentation, balance billing prohibition compliance, and patient communication management.
- Good Faith Estimate preparation for all required patients
- Notice and consent form management and documentation
- Balance billing restriction compliance review
- State-specific balance billing law compliance audit
Underpayment Analysis & Appeals
We analyze every OON payment against Medicare benchmarks and applicable state laws, identifying systematic underpayment patterns and filing targeted appeals with documented justification.
- Payment analysis against 200% Medicare benchmark
- Systematic underpayment pattern identification by payer
- Formal appeal letters with supporting documentation
- Reprocessing requests for improperly paid claims
ERISA Self-Funded Plan Billing
Self-funded employer health plans (governed by ERISA) have different rules than fully insured commercial plans. We navigate ERISA-specific claims submission, appeals, and litigation support requirements.
- ERISA plan document requests and review
- Internal appeal and external review submissions
- 60-day mandatory appeal deadline tracking
- ERISA litigation support documentation preparation
The OON Revenue Gap
Everything you need to know about outsourcing your credentialing
to ProvidaRCM. Don't see your question? Contact us directly.
Free OON Revenue Analysis
Without active negotiation, payers pay OON claims at their lowest internally-determined rate. With ProvidaRCM, every underpaid claim is challenged, and most are significantly improved.
OON Billing Expertise Across
Every High-Value
Specialty
OON billing is most impactful for specialties where in-network rates significantly undervalue services. We have deep experience in all of these.
Out-of-Network Billing FAQs
Yes, and in many cases more viable than before. The No Surprises Act changed the rules for emergency care and services at in-network facilities, but OON billing for scheduled outpatient care with appropriate patient consent remains legal and financially compelling. The IDR process also gives providers a structured path to challenge underpayments that didn’t exist before 2022. ProvidaRCM helps OON practices navigate the new rules while maximizing reimbursement.
The GFE requirement applies specifically to uninsured and self-pay patients for scheduled services. For insured patients with OON coverage, the payer is responsible for providing an Advanced EOB, not the provider. However, some states have broader GFE requirements that apply to insured patients as well. ProvidaRCM conducts a state-specific compliance review for every practice to determine exactly what notices are required for your patient population.
The federal IDR process applies to fully insured commercial plans and most employer-sponsored plans that are not self-funded. Self-funded ERISA plans are technically exempt from the federal IDR process, though they have their own internal and external review requirements. For self-funded plans, ProvidaRCM pursues recovery through ERISA-specific appeals, external review, and, when justified, litigation support. We navigate both federal and ERISA tracks depending on the payer type.
IDR uses a “baseball arbitration” model, the arbitrator picks either the provider’s offer or the payer’s offer, with no splitting the difference. This makes offer strategy critical. ProvidaRCM analyzes the Qualifying Payment Amount (QPA) calculated by the payer, benchmarks it against actual Medicare rates, comparable in-network rates in your geographic market, the complexity of the service, and your training and experience level. We then set an offer that is aggressively above the QPA but well-supported by the documentation, maximizing the arbitrator’s confidence in selecting our number. This strategy is why our IDR win rate sits at approximately 72%.
Yes, and many practices do exactly this. You can selectively participate in the payers whose fee schedules make in-network worthwhile while remaining OON for payers whose contracted rates undervalue your services. ProvidaRCM can help you analyze your current payer contracts, identify which payers are worth staying in-network with based on volume and rate, and manage OON billing for the remainder. This hybrid approach often produces the highest overall revenue per service for specialty practices.
If a payer refuses to participate in the IDR process or fails to pay within the required 30 days after an IDR decision, ProvidaRCM escalates the matter to CMS enforcement. The No Surprises Act gives CMS authority to investigate payer non-compliance and impose civil monetary penalties of up to $100 per day per violation. We document every step of the IDR process precisely so that any payer non-compliance is fully documented and reportable. In cases involving self-funded ERISA plans, we coordinate with legal counsel to pursue ERISA-specific enforcement mechanisms.
It depends on your specialty, patient volume, and payer mix — but for many solo and small practices, OON billing can be significantly more profitable than in-network participation. The key question is whether your patients will seek you out regardless of network status. If you have a strong referral base, subspecialty expertise, or are in an area with limited competition, OON billing can increase your per-procedure revenue by 2–3× compared to contracted rates. ProvidaRCM offers a free OON feasibility analysis for solo and small group practices, we review your current payer mix, procedure volume, and local market rates to give you a realistic picture of what OON billing would mean for your bottom line before you make any changes.