AI-Powered Solution by Zelis to Navigate No Surprises Act Disputes
Health technology company Zelis has introduced a groundbreaking AI solution designed to assist health plans in managing the complexities of Independent Dispute Resolution (IDR) under the No Surprises Act (NSA). The NSA, enacted in 2020, aimed to protect consumers from unexpected medical bills by creating a streamlined process for adjudicating out-of-network claims.
Understanding the Independent Dispute Resolution (IDR) Process
The IDR process established by the NSA is crucial for resolving out-of-network payment disagreements. However, the volume of disputes, coupled with compliance requirements and litigation timelines, has increased pressure on payers. Zelis’ AI-driven solution seeks to alleviate these challenges by automating payer workflows, ranging from claims redetermination to case management and IDR resolution.
Recent Changes in the No Surprises Act
In May, the Centers for Medicare and Medicaid Services (CMS) finalized updates to the NSA dispute resolution process. These amendments, adopted in collaboration with the Departments of Health and Human Services, Labor and Treasury, and the Office of Personnel Management, aim to reduce administrative fees from $115 to $15. This significant reduction is intended to facilitate easier participation while maintaining the program’s sustainability.
The final rule introduces enhancements such as new communication protocols, standardized claim codes, and stricter certification and batching requirements. These measures are designed to minimize ineligible disputes and improve overall efficiency within the federal dispute resolution process.
Zelis’ AI Solution: A Strategic Approach
Zelis’ AI solution is tailored to support the evolving needs of the NSA, including changing timelines and reporting requirements. The solution automates workflows, reducing operational blind spots and streamlining out-of-network claims processing. By transitioning from manual to strategic, data-driven management, payers can optimize the IDR lifecycle.
Key features include automated intake, documentation, alerts, and escalation workflows, ensuring timely case processing and mitigating risks of missed deadlines and financial losses. Furthermore, the solution offers real-time dashboards, Qualified Payment Amount (QPA) comparison analytics, comprehensive audit trails, and evidence-based pricing recommendations.
Predictive Intelligence for Enhanced Arbitration Strategies
Leveraging predictive intelligence, Zelis’ solution tailors case submissions, combats unqualified disputes, and uncovers patterns in Independent Dispute Resolution Entity (IDRE) behavior and provider practices. This capability helps optimize arbitration strategies, leading to stronger performance outcomes.
Jim Bridges, president of price optimization at Zelis, emphasized, “Rule changes by CMS and HHS have improved NSA’s efficiency and long-term sustainability, but payers are overwhelmed by the complexity and costs associated with the IDR process. Zelis NSA Claim Advantage offers payers a smarter way to manage the IDR lifecycle. It combines AI-native automation, data-driven intelligence and human review at every step of the journey to identify risks earlier, reduce avoidable disputes and replace guesswork with predictable results.”
Growing Dispute Volumes Challenge Payers
Since the inception of the federal IDR portal in 2022, the volume of disputes has exceeded expectations, reaching over 5 million by April 2022. This trend has prompted criticism from payers, who highlight that a small number of providers account for a large share of disputes. Notably, providers tend to win a significant majority of cases referred to arbitration, with an 87% success rate in the second quarter of 2025.
Zelis’ solution builds on its extensive claims processing experience, having achieved $2.39 billion in NSA claims savings in 2025, with only 8% of claims escalating to IDR. Serving over 750 payers, Zelis collaborates with major national and regional health plans, TPAs, and healthcare providers.
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