The right No Surprises Act vendor screens claims for eligibility before filing, is clear about exactly what its fee applies to, manages every deadline, handles both federal and state processes, signs a HIPAA business associate agreement, and reports results claim by claim. Most of the difference between vendors comes down to how they answer those six questions.
This guide covers the main types of help available to out-of-network providers, what to compare between them, and the red flags worth walking away from.
The five ways to get disputes handled
| Option | Works well when | Where it tends to break |
|---|---|---|
| In-house billing team | Someone owns the deadline calendar full time | The 4-business-day initiation window and batch construction — unforgiving, and not what billers are trained for |
| Law firm | There’s a real legal dispute: an unpaid award, a coverage fight, a payer pattern | Expensive per claim for routine filings that are mostly evidence, not argument |
| Contingency filing service | You want it handled end to end with no upfront cost | Depends entirely on screening discipline and on what the fee applies to |
| Software platform | You have staff and want control with better tooling | The work doesn’t disappear; it gets better organised |
| RCM add-on | Your billing company already offers it | IDR is often a side line rather than a specialism |
None of these is wrong. The question is which failure mode you can live with.
What to compare
1. Eligibility screening before filing
Not every out-of-network claim qualifies for federal IDR. A claim may fall under a state surprise-billing law instead, involve a plan type the federal process doesn’t cover, or have missed open negotiation entirely.
Filing ineligible disputes wastes the fees and invites payers to challenge your submissions in bulk. Ask how the vendor screens claims before filing, and what share of its filings are found ineligible. A vendor that can’t answer has probably never measured it.
The criteria are set out in our federal IDR eligibility checklist.
2. What the fee actually applies to
Most full-service vendors work on contingency. The headline percentage matters less than the base it’s applied to:
- The whole payment, including what the plan already paid before any dispute, or
- Only the increase the dispute recovered.
On the same claim at the same percentage, those produce very different bills. Get the answer in writing, with a worked example on one of your own claims.
3. Who pays the federal fees
Every federal IDR dispute carries a non-refundable administrative fee for each party, plus the certified IDR entity’s fee, which is refunded to the party that prevails. Ask whether the vendor passes these to you or absorbs them — and specifically what you owe on a dispute that’s lost.
4. Deadline management
The No Surprises Act runs on short, fixed clocks:
- Open negotiation must be started within 30 business days of the initial payment or denial, and runs for 30 business days.
- Federal IDR must be initiated within 4 business days after open negotiation ends.
- A plan must pay an IDR award within 30 calendar days of the determination.
A missed window can’t be recovered. Ask who owns the calendar, and how a claim is tracked from remit to payment. Our federal IDR timeline walks through each stage.
5. Federal and state coverage
Some states run their own surprise-billing dispute processes, and for claims governed by those laws the federal process doesn’t apply. A vendor that only handles federal IDR will either turn those claims away or file them in the wrong forum. See federal vs. state IDR.
6. HIPAA compliance
A vendor handling your remittances, EOBs and claim records is working with protected health information. That makes it a business associate under HIPAA, and it should sign a business associate agreement (BAA) before you send it a single claim.
Ask how claim files are transmitted and stored, and who can access them. If a vendor hesitates about a BAA, stop there.
7. Offer strategy
IDR entities may not consider billed charges, usual and customary charges, or Medicare and Medicaid rates. Offers built on those carry no weight. Ask how the vendor builds an offer, and listen for the permitted factors: patient acuity, service complexity, provider training and experience, and contracting history. Background in our guide to the qualifying payment amount.
8. Reporting and data ownership
You should be able to see every claim’s status and outcome, broken down by payer, and you should keep that data if you leave. Payer-level results tell you where to push in contract negotiations, which is worth something beyond the disputes themselves.
9. Support
Ask who you’ll actually speak to, how quickly they respond, and whether you get a named contact or a ticket queue. When a payer misses an award payment, you want a person who already knows the claim.
Red flags
- No eligibility screening — “we file everything” usually means paying fees on claims that were never going to qualify.
- A fee base that’s vague — if the vendor can’t say whether the percentage applies to the whole payment or only the increase, assume the more expensive answer.
- Reluctance to sign a BAA.
- A headline win rate with no volume behind it — ask how many disputes were decided, over what period, for which specialties.
- Offers anchored to billed charges or Medicare multiples — the IDR entity can’t consider either.
- Lock-in on your data — you should be able to take your claim history with you.
Questions to ask before you sign
- How do you screen claims for eligibility, and what share of your filings are found ineligible?
- Is your fee a percentage of the whole payment, or only the increase you recover?
- Who pays the administrative and IDR entity fees, and what do I owe on a lost dispute?
- Who owns the deadline calendar from remit to payment?
- Do you handle state processes as well as federal IDR?
- Will you sign a HIPAA business associate agreement?
- How do you build an offer?
- What reporting will I see, and do I keep my data if I leave?
- Who is my day-to-day contact?
How Teramed answers them
We’d rather you ask every vendor these questions — including us. Our answers:
- Eligibility screening. Every claim goes through a pre-filing eligibility check before anything is filed.
- Fees. A percentage of the increase we recover above the plan’s original payment — never of what you’d already been paid. Nothing upfront, no retainer, no minimum. See pricing.
- Federal fees. We absorb the administrative and IDR entity fees. If a dispute is lost, you owe nothing.
- Deadlines. Your front desk forwards the remit. We own open negotiation, filing and payment follow-up.
- Federal and state. We determine which process applies to each claim and handle both.
- HIPAA. We sign a business associate agreement before receiving any claims data.
If you’d like to see how this works on your own claims, send us a sample of recent out-of-network remits and we’ll tell you which are IDR-eligible. Get in touch.
This guide is general information, not legal advice. Confirm current requirements at cms.gov/nosurprises.