RevGuard — We guard your bottom line.
Out-of-network (OON) revenue is no longer about sending a claim and waiting. Under the No Surprises Act, reimbursement is governed by strict timelines, defined processes, and strategic escalation.
This playbook outlines how RevGuard recovers OON revenue systematically, compliantly, and predictably — from claim submission through arbitration and collections.
Why OON Revenue Fails
- Missed NSA timelines
- Weak documentation
- Poor negotiation strategy
- Reactive or inconsistent IDR use
- No post-award enforcement
OON success requires orchestration — not hope.
Phase 1: Claim Qualification & Documentation Hardening
RevGuard verifies:
- NSA eligibility
- Care setting and provider role
- Documentation completeness
- Coding defensibility
Phase 2: Strategic Claim Submission
- Payer-specific submission rules
- Clear medical necessity framing
- Early leverage positioning
Phase 3: Open Negotiation (30 Days)
- Offer evaluation vs. expected recovery
- Data-backed counteroffers
- Decision gate: resolve or escalate
Phase 4: IDR Viability Modeling
- Expected award vs. QPA distortion
- Filing fees vs. net recovery
- Payor arbitration history
Only high-value disputes proceed.
Phase 5: IDR Filing & Strategy
- Evidence narrative construction
- Offer positioning
- Deadline control
Phase 6: Decision & Award Tracking
- Real-time outcome monitoring
- Statutory payment deadlines tracked
Phase 7: Post-Award Enforcement
- Payor follow-up
- Escalation workflows
- Reconciliation to deposits
Phase 8: Optimization & Intelligence
- Payor behavior analysis
- Dispute prioritization
- RCM improvements upstream
Bottom Line
OON revenue is earned at the bedside — but protected through process.
RevGuard — We guard your bottom line.