Points of view

Most out-of-network dollars are lost before a dispute ever reaches an arbitrator. By the time someone spots the shortfall, the window to negotiate or file has often closed. Meanwhile, the independent dispute resolution (IDR) report shows a strong win rate, so leadership sees success while recoverable reimbursement disappears from accounts receivable (A/R) and the cash forecast. 

The fix is an operating change.

The change starts with treating out-of-network reimbursement as a series of deadlines instead of a single payment. Under the No Surprises Act, a health plan pays for out-of-network emergency care and certain services at in-network facilities based on its qualifying payment amount (QPA). Providers who believe that payment is too low can challenge it on a fixed schedule. They have 30 business days to start negotiation, 30 business days to reach agreement, and four business days to file for federal IDR. 

Each deadline depends on someone noticing the claim in time. Here's how to make sure someone does:

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Give one owner the clock. | Assign One Recovery Owner

The most effective recovery model assigns a single accountable owner to every eligible claim from initial payment through posted award. Ownership means control of the deadline, the evidence file, and the decision to negotiate, file, or accept. Specialist teams do the work, but the owner sees each claim’s position on the clock and escalates before a window closes.

This structure changes the economics of A/R follow-up. Disputed claims stop aging as generic receivables and move as time-bound recovery work with a known value and a known deadline. An owner needs to know where each claim can fail and which signal shows the problem early.

Where out-of-network recovery leaks

File where net recovery beats the cost. | Prioritize Disputes by Recoverable Value

Filing a dispute has a cost, even when the provider wins. Since administrative and certified entity fees apply to each dispute, low-dollar claims recover more value when they’re batched correctly or settled in open negotiation. The right portfolio balances recovery value against cost-to-collect.

Disputes earn priority when they score well on:

• Expected recovery above the QPA, net of filing fees and labor
• Days remaining in the active window
• Evidence strength, including patient acuity, clinician training, and prior contracted rates with the plan
• Recurrence, where one payer’s methodology repeats across hundreds of claims

Recurring underpayments deserve the most executive attention. One payer underpaying a common emergency department code across hundreds of encounters points to a methodology problem. Resolving it once through open negotiation and revenue integrity review protects every future claim with that code. Rules-based scoring and artificial intelligence (AI) rank this inventory daily, directing specialists to the highest-value claims closest to deadline.

Build recovery that survives the next rule change. | Prepare for IDR Rule Changes

Federal IDR volume keeps rising: CMS data shows about 1.19 million disputes in the first half of 2025 and 1.37 million in the second. As volume grows, payers are pushing back harder. They challenged 42% of disputes as ineligible in the third and fourth quarters while pressing regulators and courts to narrow the process. Health systems should expect the rules to keep shifting.

Clean intake and claim-level evidence hold their value through any rule change. Health systems that verify QPA disclosures and batching criteria before filing are better positioned to clear tighter eligibility review. If the process moves toward a fixed benchmark, leverage shifts to QPA validation, payment timing, and contract strategy. Variance detection, evidence files, and payer-level history support recovery in every one of these scenarios.

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Recovery is an operating decision. | Recovery Is an Operating Decision

Out-of-network reimbursement looks like a legal question until leaders map where the dollars leave. The losses concentrate in the handoffs between posting, variance review, negotiation, and filing, and they stay hidden whenever success is reported as a win rate. The signal worth elevating is recovery yield, tracked from eligible dollars identified through dollars posted.

Vee Healthtek connects posting, variance review, open negotiation support, and A/R follow-up into one governed recovery workflow, so out-of-network claims stop changing owners as they move toward a deadline. Specialists with deep revenue cycle expertise validate shortfalls against contracts and QPA disclosures, while RevAmp consolidates the inventory and ranks each claim by recovery value, urgency, and recoverability. The workflow design keeps evidence assembly upstream, which shortens the time from flagged variance to defensible offer.

Under Open Accountability, performance is judged by outcomes instead of activity, so leaders see eligible claims identified, disputes filed on time, awards won, and awards posted as cash. Findings from recurring shortfalls flow back into revenue leakage prevention and payer strategy, which makes out-of-network reimbursement more predictable for finance. The result is a recovery program built on first-pass performance, where the clock is managed from the first remittance instead of rescued at the filing deadline.

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Key Takeaways

• Fixed federal deadlines turn every handoff between posting, variance review, and managed care into a risk to cash.
• A strong IDR win rate can hide eligible claims that never reached negotiation and awards that never posted.
• A single owner for the full federal timeline gives each disputed claim a known value, a known deadline, and a clear escalation path.
• Ranking disputes by net recoverable value and recurrence directs specialist time to the claims with the largest cash and contract impact.
• Recovery discipline built on clean intake and claim-level evidence protects reimbursement as IDR rules continue to change.

Providers win most Independent Dispute Resolution (IDR) disputes, which makes the win rate the least useful number on the dashboard. In 2025, providers prevailed in roughly 86% of federal payment determinations, so winning is rarely the problem. The money slips away in the gap between a decided dispute and a deposited dollar, through claims never flagged, deadlines missed, and awards paid short. These gaps surface months later as unexplained swings in accounts receivable (A/R) and margin. Organizations recovering the most track a different figure: net cash collected per eligible claim.

Out-of-network reimbursement under the No Surprises Act (NSA) is what a health plan pays a provider for protected emergency, ancillary, and air ambulance services delivered without a network contract. When the two sides fail to agree on the amount, the federal IDR process settles it. The real question facing healthcare chief financial officers (CFOs) and revenue cycle leaders is how much of this value turns into cash, and how predictably. The seven signs below show where it leaks and how to stop it.

Sign 1: Win rates climb while cash falls. | High Wins, Falling Cash

Out-of-network cash falls year over year while the IDR win rate holds steady or climbs. The federal win rate counts only disputes reaching a payment determination. Claims closed as ineligible never enter the calculation, and eligible claims nobody filed never appear at all. A team winning nearly every dispute might be filing on a small share of what it’s owed, and the dashboard gives no warning.

A better measure compares net cash collected with the total value of every eligible claim, filed and unfiled. This ratio exposes the leakage a win rate hides, from claims never flagged to awards never collected.

Sign 2: Awards post short or late. | Awards Posting Short

Won awards post below the determination amount, or months after it, and nobody flags the gap. Most teams close the case once a determination comes back. The award then reaches the posting team with no link to the original dispute, and a short payment looks like routine variance. Weeks later, the shortfall is buried in a contractual adjustment and the recovery is gone.

Payment posting and reconciliation built around the determination amount closes this gap. Paired with an underpayment recovery path for shortfalls, each award becomes a tracked receivable with an owner and a due date. The same principle drives the move from contract to cash: an identified dollar has value only once it posts.

Sign 3: Few claims reach negotiation. | Few Claims Reach Negotiation

Out-of-network volume holds steady while few claims ever reach open negotiation. The initial payment or denial starts the open negotiation clock. When posting staff record it as a standard adjustment, an eligible claim slides silently out of view before anyone checks NSA eligibility. Emergency professional fees, anesthesia, radiology, and pathology carry the most exposure, since the surprise billing protections cover clinicians the patient never chose at an in-network facility.

The 2026 Federal IDR Operations rule requires plans to use claim adjustment reason codes (CARCs) and remittance advice remark codes (RARCs) to signal NSA coverage, giving posting teams a machine-readable trigger. Workflow automation such as RevAmp routes flagged remittances into a dedicated recovery queue, so eligibility is settled at payment instead of rediscovered months later during complex A/R recovery. The goal matches broader revenue cycle analytics work: find leakage before it becomes a write-off.

Sign 4: Claims surface after deadlines. | Claims Found Too Late

Claims get flagged for IDR only after the open negotiation window has closed. IDR runs on a chain of short, unforgiving windows: 30 business days of open negotiation, four business days to initiate, and 10 business days to submit an offer once the certified IDR entity is selected. Of roughly 2.80 million disputes closed in 2025, only 2.23 million reached a determination, and most of the rest closed on eligibility. In this process, the deadline decides before the dispute does, and a missed window erases a strong case for good.

Most deadline failures trace back to queue design. Standard queues rank accounts by age and balance, while the most important attribute of an out-of-network claim is its next expiring window. IDR inventory therefore needs its own logic within accounts receivable follow-up, sorted by days remaining and backed by automated alerts at fixed intervals. This protects value at the stage where it is easiest to lose and hardest to win back.

Sign 5: Batches draw eligibility challenges. | Batches Facing Challenges

Batched disputes keep coming back with eligibility challenges or stalling in review. The operations rule allows up to 50 qualified line items in one batched determination when they meet federal batching and bundling requirements for the same provider, the same plan, and a similar condition. With the administrative fee dropping to $15 per party for disputes initiated on or after June 11, 2026, filing economics now favor volume.

Volume without grouping discipline creates its own risk. One misgrouped item invites an eligibility challenge and stalls every dollar in the batch. Batches built around matching service codes and shared deadlines, instead of whatever lands next in the queue, keep the entire batch moving toward payment.

Sign 6: Awards land near plan rates. | Awards Near Plan Rates

Awards keep landing near the plan’s initial payment, even on complex, high-acuity cases. The certified IDR entity starts with the qualifying payment amount (QPA), the plan’s median contracted rate, and then weighs additional credible information. Chargemaster charges carry little credibility on their own, so offers built on billed rates leave this second step empty.

Stronger submissions document patient acuity, clinician experience, market share, teaching status, and good-faith contracting history, drawing on coding, clinical documentation, and revenue integrity data the organization already holds. Built once by payer and service line, this evidence package makes each later dispute faster and cheaper to file.

Sign 7: No one reports net recovery. | No Net Recovery Owner

Ask what IDR netted last quarter after fees, and four departments give four partial answers. Managed care tracks payer behavior, the business office handles remittances, an outside firm files disputes for a percentage, and finance sees the net result months later. Each handoff adds delay and hides value. None of these groups owns the figure a CFO forecasts: net cash realized per eligible claim.

Fixing this starts with giving each warning sign a metric and a named owner:

Matching each warning sign to an owner

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Ownership spreads across six teams, and every metric rolls up to the same figure: net cash per eligible claim. Without one leader accountable for the full chain, each team hits its own target while total recovery still falls short.

Single ownership changes the economics. Denials management and appeals teams already run deadline-driven, evidence-based recovery, and extending this discipline to out-of-network disputes ties IDR to enterprise goals to accelerate cash and reduce revenue leakage. Prioritization logic transfers as well. One hospital cut timely filing losses by 47% after prioritizing long-path accounts earlier in the A/R lifecycle, the same principle IDR windows demand. The shift mirrors the broader move toward first-pass performance, where work done right upstream replaces costly downstream rescue.

How Vee Healthtek protects recovery. | Why Net Cash Decides

The IDR process rewards preparation, and most providers who reach a determination prevail. The financial risk lies outside the hearing, in remittances nobody flagged, windows nobody tracked, and awards nobody reconciled. Treating IDR as a legal sideline leaves recurring reimbursement outside the forecast and outside anyone’s accountability.

Vee Healthtek connects out-of-network remittances, negotiation deadlines, dispute evidence, and award reconciliation in one governed recovery workflow, tracking IDR value from first payment to final posted dollar. Practitioners with deep revenue cycle expertise flag eligible claims at posting, and AI-enabled workflows rank inventory by expiring windows and recovery value. Evidence drawn from coding and documentation strengthens each offer and protects reimbursement where most organizations leave it exposed. The approach follows the first-pass performance model, where work is designed to hold the first time.

Performance stays visible through Open Accountability, a partnership model built on the belief that a partner should be measured by outcomes, not activity. Leaders see eligible value, filed disputes, awards, and collected cash in one view, turning out-of-network reimbursement into a predictable line in the cash forecast. 

With lower filing costs and broader batching, organizations building a recovery workflow that runs from remittance to deposit now will recover more of what they earn, with less rework and a steadier margin.

Key Takeaways

• A high IDR win rate describes one stage and says little about how much eligible out-of-network value becomes cash.
• Most IDR leakage begins at payment posting, where eligible claims get recorded as routine adjustments before anyone checks NSA eligibility.
• Queues sorted by age and balance miss the most important attribute of an IDR claim, which is its next expiring window.
• Evidence-backed offers and disciplined batching raise award value while lowering the cost of each dispute under the 2026 federal rules.
• Single ownership and net cash per eligible claim give CFOs a forecastable view of out-of-network reimbursement.

Revenue cycle does not start with the claim.

Revenue cycle is often treated as back-office work that begins after care has been delivered and a claim is ready to be coded. My recent conversation with Rebecca Napier, MBA, FACHE, (Enterprise) VP for Finance & Administration at The University of New Mexico Health Sciences Center, on Reworked challenged that view. Revenue cycle begins much earlier, when a patient is scheduled, registered and guided through the requirements that determine whether care can move forward and reimbursement can follow.

That is also where much of the rework begins. Rebecca has worked across payer, provider and enterprise healthcare leadership. Our conversation reinforced something I see repeatedly: when an organization encounters the same problem again and again, the answer is rarely to find a better fixer. The answer is to understand why the system keeps producing the problem.

Repeated problems are often designed outcomes. | Repeated Problems, Designed Outcomes

Revenue cycle teams frequently focus on solving the immediate issue. A claim is stuck, a payment is delayed or documentation is incomplete. Someone steps in and resolves it. The immediate problem disappears, but the conditions that created it remain.

“Systems function perfectly as they’re designed to operate.”
Rebecca Napier

If an organization consistently experiences the same outcome, leaders need to examine the design behind it. The right question is not simply, “How do we resolve this case?” It is, “Why does our system keep creating cases like this?” That question moves the conversation from correction to prevention.

Heroic effort can hide a weak system. | The Cost of Heroic Effort

Every organization has people who become known as fixers. They know which claim needs special attention, whom to call and how to navigate exceptions that are not documented anywhere. Their expertise is valuable, but the organization can become dangerously dependent on it.

Rebecca described how these individuals repeatedly solve the same problem until they become the center point for the work. We often see this in revenue cycle. An experienced coder may repeatedly correct documentation, coordinate with physicians and rescue claims before submission. The work protects revenue, but it does not correct the system that keeps creating the issue.

We should value expertise without building operations that require heroics to function. Strong revenue cycle operations convert individual knowledge into better training, workflows, decision rules and accountability.

Technology can get us to the chaos faster. | Technology and Data Foundations

Our conversation naturally turned to technology and AI. Rebecca’s view was direct: technology can support a strong operating architecture, but only after an organization has completed the foundational work.

Are the data clean? Are definitions consistent? Are teams measuring performance in the same way? Do internal measures align with the benchmarks being used? Is it clear who has the authority to make a decision?

Without that groundwork, technology does not resolve confusion. It processes the confusion faster. Rebecca recalled hearing someone express excitement that AI would help the organization reach solutions more quickly. Her reaction was that unclear rules and poorly structured data could simply help the organization “get to the chaos faster.”

Before introducing AI, healthcare organizations must determine whether they have selected the right problem and created the conditions required to solve it. Otherwise, technology may amplify the same inconsistency, fragmentation and rework it was meant to remove.

Data should support a decision.

Healthcare organizations have no shortage of dashboards. The harder question is whether the information changes what anyone does.

“Once you see the data, what are you going to do with it?”
Rebecca Napier

Data should support a management decision. It should help leaders improve quality or efficiency, understand whether performance is moving in the right direction and determine whether the result aligns with the organization’s strategy. The goal is not to build the most detailed dashboard. It is to make better decisions.

Revenue cycle work makes care possible. | Connecting Revenue Cycle to Care

One of the most meaningful parts of our conversation focused on an early payer negotiation in Rebecca’s career. The financial analysis showed that accepting the proposed contract would put the provider organization under serious pressure. Supported by a leader who trusted her expertise, Rebecca recommended ending the contract and anticipated that the payer would return to the table. They did.

The deeper point was not about defeating a payer. It was about protecting the operating margin needed to care for patients today and in the future. Revenue cycle can look administrative from a distance. In practice, it helps create the financial conditions that allow healthcare organizations to continue serving their communities. Helping teams see that connection gives greater purpose to the work.

Getting the front end right reduces downstream rework. | Getting the Front End Right

We brought the conversation full circle by discussing where revenue cycle begins. It begins when the patient is scheduled.

Registration, insurance requirements, documentation and coding are connected parts of one process. Errors at the beginning can lead to delayed care, reimbursement problems and significant downstream effort. The more we get right the first time at the front end, the less work teams must repeat at the back end.

Reducing rework requires more than asking people to work harder or introducing another technology.

It requires leaders to understand the complete process, correct the system producing the problem, establish reliable data and connect every role to the mission of care. That is how we build a stronger and more sustainable revenue cycle.

About Reworked. 

Reworked  is a Vee Healthtek podcast about the healthcare leaders who refuse to accept avoidable revenue cycle rework as simply “how things work.” In each concise episode, I speak with one leader about a specific operational problem, where work was being done, undone and redone, and what it took to create a more resilient process. 

The conversations move beyond broad claims about AI and transformation. Guests share the process they re-engineered, the technology they introduced, the team behaviors they changed and the measures that showed whether the work improved. The goal is simple: every listener should leave with at least one practical idea they can take back to their own revenue cycle team. 

Continue the conversation.

Watch my full conversation with Rebecca Napier, MBA, FACHE for practical insights on payer-provider relationships, system design, data, leadership and reducing avoidable work.

The payment posted. Did the value?

“Paid” is one of the most misleading words in revenue cycle management. Payment status confirms that money moved, not that the right amount arrived. When remittance is treated as resolution, underpayments disappear into adjustments, follow-up queues, and write-offs before finance sees a gap.

Health systems need a clear way to test payment accuracy before paid claims disappear from view.

Finance and revenue cycle teams must determine whether the payment reflects the claim’s supported value and whether additional recovery justifies the cost. Payer adjudication, state law, open negotiation, and federal independent dispute resolution (IDR) under the No Surprises Act shape the path to resolution. Consistent execution turns overlooked payment gaps into informed recovery decisions.
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Paid claims require a second look. | Paid Claims Require a Second Look

‍A remittance can make an underpaid claim look complete. Once the payment posts and the account leaves active work, the remaining variance becomes harder to see and easier to recover.

Payment reconciliation brings the gap back into view by connecting the electronic remittance advice with expected payment logic, claim history, network status, service details, and the applicable recovery pathway. Without this connection, posting speed can look like success while payment variance escapes review. Fast closure has value. Fast closure at the wrong amount simply makes leakage more efficient.

Paid status can represent four different financial outcomes, each requiring a different decision:

This framework helps finance distinguish complete reimbursement from unresolved exposure and focus recovery efforts where the expected return justifies the cost.

Revenue leaks across handoffs. | Revenue Leaks Across Handoffs

Missed recovery rarely starts in one queue. Exposure grows when network status, payer rules, claim support, remittance data, and dispute deadlines pass between teams without a shared account-level view. Each handoff creates another chance for the variance to lose an owner, miss a deadline, or receive an adjustment. The claim keeps moving while the recovery opportunity stands still.

The clearest leakage points appear across:

• Network classification: Incorrect plan or provider status can route the claim into the wrong payment and follow-up logic. 
• Claim readiness: Missing modifiers, attachments, or service details weaken the basis for negotiation or dispute. 
• Posting and adjustments: Automatic contractual adjustments can suppress a variance before specialists evaluate it. 
• Variance detection: Generic thresholds can overlook payer-specific, specialty-specific, or code-level recovery patterns. 
• Eligibility and deadlines: State rules, federal eligibility, open-negotiation timing, and cooling-off requirements can determine whether recovery remains available. 
• Recovery ownership: Unclear handoffs between A/R, underpayment, denials, managed care, legal, and finance increase repeated touches and missed action dates.

Connected claims validation, claim submission, A/R follow-up, and underpayment recovery keep these handoffs visible. Root-cause feedback is equally important. Recovery teams can collect the balance once, while connected medical billing workflows can keep the same defect from weakening the next claim.

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QPA does not define recoverable value. | QPA Does Not Define Recoverable Value

‍The qualifying payment amount (QPA) is an important reference point in federal independent dispute resolution (IDR), but it doesn’t establish the full value of a claim. Treating the QPA as an automatic ceiling can remove viable recovery opportunities before teams consider claim evidence, procedural eligibility, and the cost of pursuing the difference.

Federal outcomes show why finance should look beyond the initial payment. In the second half of 2025, providers prevailed in 85% of 1.15 million payment determinations, and 87% resulted in awards above the QPA, according to HFMA’s analysis of federal IDR data. Individual outcomes vary, but the pattern reinforces a practical point: neither the payment nor the QPA offers a complete view of potential recovery.‍

Finance needs to evaluate each claim based on the amount still recoverable, the cost to collect, and the expected time to cash. Separating gross variance from expected net recovery gives leaders a clearer basis for deciding where additional effort will produce a meaningful return.

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Small claims compound exposure. | Small Claims Compound Exposure

A $200 recoverable variance may look immaterial at the account level. Across 5,000 claims, however, it represents $1 million before fees and collection costs. 

Federal data reinforce the aggregation point. Roughly 678,000 payment determinations in the second half of 2025 involved services with QPAs between $100 and $500, according to federal IDR reporting. A claim-level threshold that screens out these balances without considering volume removes significant recovery from the work plan.

Finance should prioritize small-dollar variances based on their aggregate recovery value, not their individual balances. Route repeatable patterns through standardized workflows and reserve specialist capacity for complex claims with stronger financial upside. This keeps cost-to-collect aligned with expected return from the start.

Measure the cash captured. | Measure the Cash Captured

‍Denial rates measure whether claims were rejected, not whether paid claims were paid accurately. A health system can post cash promptly, keep denials stable, and still under-realize reimbursement.Finance needs measures that show how much recoverable value remains after payment:

• Paid-claim variance rate: Shows how often paid out-of-network claims require payment-accuracy review.
• Recovery conversion: Shows whether approved recovery opportunities become additional cash.
• Time to recovery: Shows when additional payments can affect cash forecasts.
• Recovery cost: Shows whether the likely return justifies the expense and effort.
• Preventable recurrence: Shows whether workflow corrections are reducing repeat leakage.

This information shows where recovery effort will create value and where additional work will only consume capacity.

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Vee Healthtek connects recovery. | Vee Healthtek Connects Recovery

Vee Healthtek connects remittance data, expected reimbursement logic, payer-specific work queues, and recovery deadlines so paid-short claims remain visible after posting. AI-enabled workflows sort routine variances from claims requiring specialist review, while revenue cycle experts apply the evidence and recovery pathway appropriate to each account. Open Accountability keeps ownership clear and outcomes visible while the provider retains policy, governance, and decision authority.

The operating model also feeds variance findings back into posting, A/R, claims, coding, documentation, and managed care workflows. This feedback loop supports earlier detection and fewer repeat touches instead of recovering the same type of loss again. The operating discipline reflected in Vee Healthtek’s zero-backlog case study, including governed work queues, quality controls, and recurring reviews, is also relevant when out-of-network claims require coordinated ownership.‍

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Key Takeaways.

• Payment status confirms that cash moved, not that the health system received the amount supported by the claim.
• Paid-claim review distinguishes complete reimbursement from recoverable exposure and limited-value opportunities.
• The QPA informs federal IDR decisions, but it does not define the full recoverable value of a claim.
• Small payment gaps become financially significant when the same variance repeats across a high-volume portfolio.
• Paid-claim variance, recovery conversion, time to recovery, recovery cost, and preventable recurrence give finance a clearer view of realized cash.

One more edit. One more handoff. One more look at an account that was already reviewed. In large organization, those small touches disappear into the volume. In a rural health system, they add up to a real cost. 

At the Montana HFMA 2026 Fall Conference, speakers connected unnecessary work and rework to Medicaid uncertainty, artificial intelligence (AI), cybersecurity, and leadership. Each pointed to the same goal: making every resource count without compromising financial performance.

Here are my top five top insights from the Montana HFMA conference for rural health leaders.

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1. Strong leadership stretches limited capacity. | Leadership Makes Capacity Work

Rural health systems cannot hire their way out of every staffing challenge. Matt Griswold, speaker, author, and musician, talked about the importance of knowing when to lead and when to support in his “Harmony & Melody” keynote presentation.

His musical analogy offered a useful lesson about team dynamics. In music, the melody takes the lead while the harmony supports and strengthens it. Both are essential to the performance. The same idea applies to health system operations. Effective teams know who needs to step forward on a task, when others need to step in, and how their work supports a shared result.

For rural health systems, this means knowing who takes the lead as work moves between departments. Consider a claim delayed by missing clinical documentation. Coding identifies the gap, clinical staff take the lead in resolving it, and billing steps forward once the claim is ready. The melody shifts between teams, while everyone else provides the support needed to keep the work moving. Each team has a different part to play, but everyone needs to follow the same plan. 

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‍‍2. Rework drains rural capacity. | Small Teams Need Smarter Queues

‍Rural health system executives highlighted how manual payment posting, paper-based authorization processes, and repeated account touches consume valuable staff time without adding financial value. When these workflows fall out of sync, errors and unnecessary handoffs create avoidable rework.

Putting emphasis on reducing repeated corrections helps health systems reclaim capacity. Accurate patient information at registration, clearer coding work queues, and timely payment posting help prevent avoidable rework and identify denials sooner. The less time employees spend revisiting the same accounts, the more capacity they have to resolve outstanding claims, accelerate reimbursement, and protect cash flow. First-Pass Performance is how rural teams turn rework into resilience.

Where rural health systems can regain capacity:

3. AI needs to prove its value. | AI Needs a Practical Starting Point

‍AI generated plenty of interest at Montana HFMA, but one question stood out: where can rural health systems put it to work without adding complexity or cost? With limited budgets and lean teams, technology investments need a clear operational purpose and measurable financial return.

The best starting point is a focused revenue cycle workflow, such as prioritizing claims for follow-up or identifying documentation gaps. Before expanding, leaders need to establish accountability, validate accuracy, and measure whether automation actually reduces staff workload. Faster processing means little if employees spend the time they saved correcting errors.

The real test comes after implementation. Approved tools, human oversight, and clear escalation procedures help keep AI reliable as workloads and exceptions change. 

4. Medicaid uncertainty threatens rural cash flow. | Coverage Risk Starts Upstream

‍One of the biggest financial concerns raised by executives was Medicaid uncertainty. Changes in eligibility requirements create a real risk for rural health systems and put additional pressure on already tight margins. 

Timing makes all the difference, since identifying coverage gaps before service gives rural health systems more options to protect reimbursement. Stronger eligibility verification, accurate registration, and timely prior authorization help prevent avoidable denials, while early financial counseling gives patients a chance to address coverage gaps. Once an account reaches collections, the health system has fewer options and has already absorbed the cost of additional work.
 

5. Cybersecurity is a cash issue. | Cybersecurity Is a Cash Issue

‍One of the more sobering discussions at Montana HFMA centered on phishing and payment fraud. Attendees shared experiences that underscored the financial risks facing rural health systems, where a single fraudulent transaction can put significant pressure on limited cash reserves and disrupt essential operations.

For rural health systems especially, cybersecurity deserves a place in the broader conversation about financial resilience. Independent verification of banking changes, restricted system access, and clear incident response procedures help protect cash and maintain business continuity. 

Finance and IT leaders also need defined responsibilities for identifying suspicious transactions, escalating concerns, and authorizing payments. A simple verification step can prevent a costly financial loss and weeks of disruption. For rural health systems operating with limited resources, prevention is far more manageable than recovery.

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What I took home. | What I Took Home

Just as a successful musical performance depends on everyone playing their part, rural health systems need their people, processes, and technology working in sync. 

For healthcare leaders, stronger performance begins with recognizing where coordination breaks down and addressing the causes. Preventing Medicaid-related denials, reducing unnecessary work, and introducing AI responsibly all depend on clear ownership and making better use of existing resources.

Rural health systems don’t need every department playing louder. They need everyone playing together to protect cash flow, strengthen margins, and make limited capacity go further.

Key Takeaways

• Coverage checks before service help protect reimbursement and reduce avoidable denials.
• Exception-based queues direct limited staff time toward accounts with cash impact.
• Small AI pilots need accuracy checks and explicit ownership before expansion.
• Payment-change verification and incident readiness support business continuity.
• Clear handoffs make shared expertise more useful to rural teams.
  

Patients never see an organization chart, but they feel every handoff between its departments. When information stalls between steps, or no one owns the gap, patients absorb the confusion and the organization absorbs the rework.

Panelists at the 2026 New Jersey & Metro Philadelphia HFMA 50th Annual Institute named this fragmentation as a leading source of patient frustration. Whether the topic was estimates, denials, automation, or payment, the problem and the fix both lived in the handoff.

These five takeaways each name a handoff, and what leaders can do to keep it from becoming the patient's problem.

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1. Estimate accuracy decides whether patients trust the final bill. | Estimate Accuracy Matters

The patient financial experience panel, with leaders from Penn Medicine Princeton Health, Hackensack Meridian Health, Cooper University Health Care, and Holy Name Medical Center, called estimate accuracy critical but rarely measured. An estimate is a promise made at scheduling and registration and kept or broken later by a different team. 

The panel compared an estimate to a car repair quote, and the analogy stuck with me: when quote and final bill diverge, trust takes the hit. Billing problems often overshadow good clinical care, so organizations were encouraged to adjust bills within a reasonable range, while price transparency laws raise the stakes for accurate quotes.

2. Registration-driven and payer-driven denials need different fixes. | Identify Denial Sources

Panelists called denials a growing drag on payment and staff time, led by front-end and coordination of benefits denials, and said payers use them to delay payment. This creates two lanes. In one, registration creates the denial through outdated eligibility data or a missed secondary payer. In the other, payer behavior does, and industry groups are pursuing regulatory action.

One published review of 240 eligibility denials traced top causes to missing documentation, incorrect insurance and demographic data, and manual delays. Tagging each denial by lane shows which preventable denials need registration staff education and which belong in payer escalation, so denials leaders know who owns the fix.

3. Design the exception path before automating routine work. | Design Exception Paths

Audience polls put denial management, authorizations, and claim status updates atop the automation list. Payers already use artificial intelligence (AI) to increase denials, and patients are increasingly using ChatGPT to dispute bills, so disputes can outrun a manual queue. Executives agreed that automation offers the best method to answer AI-driven denials faster and more accurately.

Panelists drew the line at relationships: digital tools should enhance the human element rather than replace it. The handoff between machine and person is the design problem, so teams should redesign the workflow and its exception path before automating routine work. Otherwise, automation has simply built a faster queue.

4. Familiar, well-timed payment options bring in more cash. | Simplify Patient Payments

One speaker reported a 400% increase in emergency department (ED) copay collections after moving to tablet-based registration. The tablets improved registration accuracy and eased the emotional burden on staff handling payment conversations.

Adoption follows trust, so digital payment options should be familiar. Discounts around tax season or year-end and installment plans built to Medical Debt Relief Act guidelines meet patients when they can pay. Each tactic also lowers cost-to-collect when it replaces a statement cycle or follow-up call, a result finance leaders can verify.

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5. Write patient standards into every collection partner agreement. | Set Partner Standards

Speakers in a second session described the partners who support collections and payment as patient advocates offering consistent, empathetic help. Once an account moves, patients hear the organization's voice through that partner, and negative experiences carry a disproportionate reputational cost.

Four terms belong in every partner agreement:

• Shared communication records, so patients never retell their story
• Unified messaging across every channel
• Human responses to digital outreach
• Early identification of self-pay patients who qualify for aid

It’s important to review partners against recovery rate, bad debt percentage, and patient satisfaction together, so recovery gains never hide a damaged relationship.

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Own the handoffs. | Own the Handoffs

Estimates, denials, automation, payment, and partners looked like five separate problems, but each came down to whether information and ownership crossed the gap intact. Patients judge the whole organization by how that moment feels, and a department-level dashboard never captures it. Leaders who follow one patient from scheduling to statement, and name an owner at every seam, will see exactly where trust and cash slip away.

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Key Takeaways

• Estimate accuracy and first-call resolution show whether promises and answers survive handoffs, before gaps become disputes and rework. 
• Tagging denials by origin sends registration-driven losses to training and payer-driven losses to escalation. 
• Automation answers payer AI and patient disputes only when exceptions have a trained human owner. 
• Familiar, well-timed payment options lifted one organization's emergency department copay collections 400%, and lower cost-to-collect when they replace a follow-up call.
• Partner agreements requiring shared records, unified messaging, and human responses protect patient trust alongside recovery rates.

From connection to execution.

Open@Epic 2026 brought developers and healthcare leaders together around connectivity and implementation. What stood out to me from the conference was how quickly a strong connection can lose value in a real revenue cycle workflow. Across sessions and conversations, people returned to the same challenge: moving data is only the start. Financial value appears when a connection advances an account, reduces manual work, or exposes reimbursement risk earlier.

I left with five takeaways for revenue cycle leaders: standards enable connectivity, workflow ownership creates value, and governance supports scale.

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1. Connections must survive real work. | Connections Must Survive Real Work

‍A recurring theme at Open@Epic was the importance of moving beyond successful integration to reliable, repeatable execution. Once an integration goes live, it needs to handle the demands of daily operations, including high transaction volumes, incomplete information, and unexpected exceptions. Any disruption can affect revenue cycle performance, making reliability a financial priority as much as a technical one.

For revenue cycle leaders, this distinction has financial implications. An integration that works inconsistently can still create manual workarounds, delay authorizations, or leave accounts waiting for information needed to move forward. Testing before launch and monitoring after go-live mean less troubleshooting and more time improving workflows. 

2. APIs need someone accountable. | APIs Need Someone Accountable

Application programming interfaces (APIs) need an operational owner. Each use case needs a defined trigger, exception path, documentation standard, and accountable team.

The opportunity for health system CFOs and RCOs is to connect API performance to workflow outcomes. Tracking whether accounts advance, exceptions are resolved, and manual follow-up decreases provides a more meaningful picture than transaction volume alone. 

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From API response to revenue cycle results

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3. Agents must earn their keep. | Agents Must Earn Their Keep

Agentic AI generated plenty of interest, but the more useful question is where it adds value. Agentic automation fits best where volume is high, rules are defensible, and exceptions are bounded. Eligibility verification fits the bill well: automation handles repeatable checks while practitioners resolve ambiguous coverage or payer responses. Coding, payer-policy research, and A/R follow-up offer similar potential. 

A useful way to evaluate an agent is to follow one account from start to finish. Did the system retrieve the correct information, make an approved recommendation, and hand off a genuine exception to the right person? 

A faster automated step is helpful. A resolved account, with less rework and a clear audit trail, is a business result.

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4. Governance starts before launch. | Governance Starts Before Launch

Governance belongs in the original design. Conversations about autonomous workflows at the conference raised a familiar risk: capability can expand faster than accountability. Human validation, role-based permissions, auditability, security controls, and escalation thresholds need to be defined before launch. Retrofitting them after a workflow has started changing accounts is an expensive way to discover who owns the decision.

Revenue cycle AI governance needs to establish who authorizes an action, which evidence the system uses, which changes require review, and how drift is detected. These controls are especially important for coding, authorization, payer-policy interpretation, and claim changes. 

5. Better data, sharper decisions. | Better Data, Sharper Decisions

Better data exchange should sharpen decisions, not simply add another source of information. Combining claim, remittance, contract, and payer-policy data can expose where expected reimbursement diverges from payment. A useful signal identifies which variance deserves attention, who owns it, and how long the organization has to act. 

Comparing payer performance across sites can reveal recurring underpayments or claims stuck at the same handoff. Route those issues before they age into unpaid balances, then use the pattern to prevent recurrence.

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Production value is the test. | Production Value Is the Test

The conversations at Open@Epic reinforced something all technology leaders need to keep front and center: the best innovations make complex work simpler for the people relying on them. This means choosing where technology can make the greatest difference, building accountability into the workflow, and measuring success by what improves for the organization.

For revenue cycle leaders, the test comes after implementation. Are accounts moving forward with fewer manual interventions? Are exceptions being resolved before they delay reimbursement? Are teams gaining capacity without sacrificing accuracy? These outcomes tell us far more about the value of an investment than the number of integrations completed or tasks automated.

A successful demo gets people excited. Seeing technology perform reliably in daily operations is what builds confidence and justifies continued investment. The real achievement is turning technical progress into financial performance that lasts.

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Key Takeaways

• Interoperability creates value when a live workflow reaches a measurable financial outcome.
• API success depends on ownership of routing, exceptions, documentation, and the next account state.
• Agentic workflows need a unit-level business case tied to resolved work, accuracy, and cash impact.
• Governance designed before launch protects auditability, scalability, and reimbursement integrity.
• Technology and finance leaders need shared measures that connect system events to revenue cycle results.

Fast money has fine print. | Faster Payments Could Weaken Cash

A 30-day payment requirement sounds like a cash-flow win for health systems. The catch is the price. 

The new Lower Premiums, Faster Payments Act proposes replacing federal Independent Dispute Resolution (IDR) with a payer-set Qualifying Payment Amount (QPA) as the final out-of-network rate. Cash will arrive sooner, but at a lower rate and with limited ability to challenge how it was calculated. If passed, a payer’s formula will set the value of every protected out-of-network claim.

Arbitration gives providers a way to contest a payer's number. Without it, the fight shifts to contract strategy and claim accuracy. Health systems that measure speed and value together can catch payer errors early, no matter what Congress decides.

Here’s what CFOs need to know about the Lower Premiums, Faster Payments Act.

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Background: what changes when the QPA becomes the final payment. | What the Proposal Changes

Under current law, both providers and payers can move an eligible No Surprises Act payment dispute from open negotiation into federal IDR. The proposed legislation removes this pathway for most covered services after the proposed effective date, making the recalculated QPA the final out-of-network payment rate. 

The QPA is the median rate a health plan has contracted with providers for the same or similar service in a geographic area. The bill changes how that benchmark is set for 2028. It starts from eligible rates as of January 31, 2019, applies adjustments for incentive and retroactive payments, and then increases the result using the Consumer Price Index. Because payers calculate the QPA, the bill adds federal rule updates, annual audits, and public reporting to check their work. 
 

Four ways a faster payment can land. | Four Payment Outcomes

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CFO action: run the numbers before the payer does. | Quantify Exposure Now

Whether the Lower Premiums, Faster Payments Act passes is out of your hands. Knowing what your out-of-network claims are worth is entirely in them. 

Build a claim-level model instead of relying on a systemwide estimate. Segment covered out-of-network claims by payer, specialty, legal entity, and service type. Compare realized collections with a modeled QPA, then combine the yield difference with changes in payment timing, dispute fees, and labor. This reveals whether faster cash improves working capital or simply brings a smaller payment sooner.

The executive view should answer five questions:

1. How much revenue currently depends on IDR outcomes?
2. Where is the largest gap between modeled QPA and realized payment?
3. Can the organization prove bill transmission and identify late payment quickly?
4. What payment variance remains recoverable?
5. How could the change affect cost-to-collect, A/R days, and operating margin?

Start with existing A/R recovery and denial management data to set the baseline. The answers will reveal the largest gaps and who should own them.

CFO action: set one owner, one source of truth, and one escalation trigger. | Assign Ownership and Controls

Name one owner for QPA methodology, payer variance, and transition decisions, then give that person authority across contracting, treasury, billing, and revenue integrity. Measure the role on net yield against the modeled QPA instead of days to payment alone, so speed doesn’t hide a weaker yield. Two controls make the role work: a single source for expected QPA, and a documented payment-clock trigger with escalation thresholds for late or underpaid claims.

CFO action: separate pre-2028 claims from claims paid under the new benchmark. | Manage Two Claim Portfolios

If the bill advances, health systems will manage two populations at once: pre-2028 claims that remain eligible for IDR and later claims paid under the new benchmark. Combining them in one queue will distort aging, productivity, and recovery reporting. Keep pre-2028 and later claims in separate queues, so leaders can see whether legacy cleanup or the new benchmark is driving results.

How Vee Healthtek keeps you ready, bill or no bill. | Build Readiness Before 2028

CFOs do not need to predict the bill’s final form to prepare. They need a defensible exposure model, clear QPA ownership, and workflows that prove when payment is late or wrong. Even if the bill doesn't pass, the same model still exposes underpayments in today's out-of-network claims.

Vee Healthtek traces covered out-of-network claims from source data through payment to identify where time or value gets lost. Practitioner-led analysis connects claim classification, payer response, posting, and variance resolution, then converts recurring defects into workflow changes that prevent avoidable rework and improve reimbursement predictability.

Open Accountability keeps ownership and results visible. Leaders can see whether each intervention improves payment timing, reduces incorrect adjustments, and strengthens recovery instead of measuring completed activity. This creates a practical readiness plan CFOs can use, even if the bill never becomes law.

Key takeaways

• The final payment moves from an arbitration award to a payer-calculated benchmark, which closes off any chance to collect above it.
• A 30-day clock can speed cash, but the benchmark can lower the amount, so speed and value belong in one measure.
• A claim-level model by payer and specialty exposes gaps that systemwide averages hide.
• One owner for QPA accuracy and the payment clock makes late and incorrect payments visible and actionable.
• Tracking pre-2028 and later claims separately keeps legacy cleanup from masking how the new benchmark performs.