Are You Leaving Money on the Table? Signs Your Practice May Have IDR Opportunities

Many physician practices assume that once an insurance company issues payment, the claim is closed and there is little left to do. But in today’s healthcare environment, that assumption can leave significant revenue uncollected.

Under the No Surprises Act, qualifying healthcare providers have access to the Independent Dispute Resolution (IDR) process when they believe reimbursement for certain out-of-network services is insufficient. While hospitals often have dedicated teams reviewing these opportunities, many specialty practices, physician groups, and ambulatory providers simply do not have the time or resources to identify eligible claims.

The result? Potential reimbursement opportunities may go unnoticed.

What Is an IDR Opportunity?

An IDR opportunity exists when a qualifying out-of-network claim receives payment that may not accurately reflect the value or complexity of the services provided. The federal IDR process allows providers and health plans to resolve payment disputes through an independent third-party review established under the No Surprises Act.

Not every claim qualifies, and not every underpayment should proceed through IDR. However, many practices are surprised to learn that a portion of their out-of-network claims may be eligible for review.

Sign #1: You Frequently Receive Out-of-Network Payments

If your practice routinely treats patients whose insurance plans classify your organization as out-of-network, it may be worth reviewing reimbursement trends.

Many providers accept initial payments without evaluating whether the reimbursement aligns with market rates or the complexity of care delivered. Over time, even small differences in reimbursement can add up to substantial lost revenue.

Specialties that commonly encounter out-of-network reimbursement issues include:

• Emergency medicine
• Anesthesiology
• Radiology
• Pathology
• Surgical specialties
• Interventional services
• Specialty physician practices

The higher the volume of qualifying out-of-network claims, the greater the potential opportunity for review.

Sign #2: Your Team Notices Consistently Low Reimbursement

Have you ever looked at an Explanation of Benefits (EOB) and wondered how the payer arrived at the payment amount?

Many practices experience situations where reimbursement appears significantly lower than expected, yet there is no clear explanation for the difference. While not every low payment qualifies for IDR, repeated patterns of underpayment may indicate that claims deserve a closer look.

Common warning signs include:

• Significant variation between payers for similar services
• Reimbursement that does not appear to reflect procedure complexity
• Frequent payment disputes involving the same health plans
• Large adjustments without clear justification

Identifying these trends often requires more than reviewing a single claim. Looking at payment patterns across multiple claims and payers can reveal opportunities that might otherwise be missed.

Sign #3: High-Dollar Claims Represent a Meaningful Portion of Revenue

Not all claims carry the same financial impact.

Practices that perform complex procedures or provide specialized services often have claims for which reimbursement differences can be significant. Even a small number of underpaid claims may represent a meaningful opportunity for recovery.

Because of this, many organizations focus their review efforts on higher-value claims where the potential return may justify the administrative effort required to pursue a dispute.

Sign #4: Your Staff Doesn’t Have Time to Investigate Underpayments

Most practice administrators and billing teams are already stretched thin.

Managing patient scheduling, authorizations, billing, denials, and payer follow-up leaves little time to research reimbursement disputes and track federal filing deadlines.

As a result, many potentially eligible claims simply move through the revenue cycle without additional review.

This is one of the most common reasons practices miss IDR opportunities—not because the opportunity isn’t there, but because no one has the capacity to identify it.

Sign #5: You Have Older Out-of-Network Claims That Were Never Evaluated

Some organizations focus only on current claims while overlooking historical reimbursement activity.

Depending on timing and eligibility requirements, there may be opportunities to review previously paid claims that were never evaluated for dispute potential. A review of past reimbursement activity can sometimes uncover patterns that help identify additional opportunities moving forward.

For practices that have never conducted an IDR assessment, a historical review can provide valuable insight into payer behavior and reimbursement trends.

Why Many Practices Miss Revenue Recovery Opportunities

The challenge is not simply identifying low payments. It is understanding:

• Which claims qualify under federal regulations
• Whether filing timelines can be met
• What documentation is required
• How to navigate negotiation requirements
• When pursuing a dispute makes financial sense

Without dedicated expertise, many practices determine that reviewing every potential opportunity internally is simply not practical.

How NYX Health Can Help

NYX Health helps physician practices, specialty groups, and healthcare organizations identify potential IDR opportunities and navigate the dispute process from start to finish.

Our team works with providers to evaluate qualifying claims, manage required timelines, coordinate documentation, and support the entire reimbursement recovery process. Rather than adding another responsibility to your billing team, we help uncover opportunities that may otherwise go unnoticed.

Wondering If Your Practice Has IDR Opportunities?

If your organization receives out-of-network reimbursements and has never evaluated claims for IDR eligibility, you may be leaving revenue on the table.

NYX Health can help assess your reimbursement patterns, identify potential opportunities, and determine whether the Independent Dispute Resolution process may benefit your practice.

Contact NYX Health today to learn more about our IDR support services and schedule a no-obligation review.

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References

Centers for Medicare & Medicaid Services (CMS). No Surprises Act – Payment Disputes Between Providers and Health Plans:
https://www.cms.gov/nosurprises/help-resolve-payment-disputes/payment-disputes-between-providers-and-health-plans

Centers for Medicare & Medicaid Services (CMS). No Surprises Act Overview:
https://www.cms.gov/nosurprises

American Medical Association. Independent Dispute Resolution Resources:
https://www.ama-assn.org/practice-management/sustainability/independent-dispute-resolution-process