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Why Healthcare Workflow Automation Is Necessary in 2026
Discover why healthcare workflow automation is vital in 2026 to enhance efficiency, reduce errors, and improve patient outcomes.
The No Surprises Act (NSA) is a law that went into effect in the U.S. in 2022. It was created to address surprise billing and protect patients from surprise medical bills when they use providers who are not included in their health insurance networks. Under certain circumstances, this is unavoidable. For example, when a patient visits the Emergency Department, or when an out-of-network provider, such as an anesthesiologist, works in an in-network hospital where the patient is being treated. The law limits what providers can charge patients in such circumstances as part of broader surprise billing protections.
The law was written to help protect patients from surprise out-of-network billing. However, providers soon began reporting financial and operational impacts. From 2021 to 2022, healthcare bankruptcies increased by 84%, with some providers citing the new law as a contributing factor. Of the practices affected, emergency care providers — including freestanding emergency departments — were the hardest hit. With nearly 500,000 disputes filed in just over a year, the resolution process exceeded initial projections, and more than 60% remained unresolved as of mid-2023, making it harder for providers to resolve payment issues.
As a result of the NSA, billing out-of-network now results in lower reimbursements. With the elimination of balance bills, providers are forced to accept the out-of-network insurer’s payout, which often results in only 70%-80% of the normal billing rate. This has affected overall healthcare costs for medical providers and influenced downstream factors such as health insurance premiums.
In the past, providers could bill health insurance and then continue billing patients for whatever insurance didn’t pay. This was called “balance billing,” and it covered the provider if the payout was less than their normal rate. In some situations, this meant a higher total payment amount for the provider. Historically, out-of-network treatments could result in higher total reimbursements from insurance companies, although commercially insured patients were frustrated when a surprise medical bill would arrive in the mail.
For the most part, balance billing beyond normal, in-network charges is no longer legal. Payment amounts are much more regulated than they were before 2022, and providers must follow specific rules before charging patients extra. This includes requirements around providing a good-faith estimate for certain scheduled services. As a result, payment disputes now go through a lengthy formal Independent Dispute Resolution (IDR) process.
Additionally, some providers report that new regulatory requirements, such as complex, timely cost estimates to patients for scheduled services, have made it harder to get claims approved. According to one report, insurers denied 37% of out-of-network claims in 2023.
Out-of-network billing is no longer the financial win that it used to be because providers are seeing lower reimbursements since the NSA was passed. In fact, insurance payments for out-of-network care are often lower than before and require extra effort to collect because of additional compliance steps within the IDR process. There’s also an added risk of penalties if the documentation isn’t exactly correct. For many practices, out-of-network care now presents more financial and administrative risk than benefit for medical providers.
The upshot is even more administrative work for billing teams and even more rules to track and follow. The added complexity piles onto an already complicated system, which leads to more errors and more back-and-forth with insurers. Over time, small mistakes can turn into more severe penalties or payment delays. Now more than ever, precise documentation is critical.
The Act will affect some providers more than others. Emergency providers or specialists, such as anesthesiologists, radiologists, or pathologists, who bill out-of-network often will feel the law’s effects right away. Facilities that relied heavily on out-of-network revenue will need to adapt to the new law. Within those practices, billing and coding teams managing claims will need additional training to perform their duties efficiently.
In light of this new legislation and ongoing surprise billing regulations, it’s important to look at how much your practice relies on out-of-network billing and adjust accordingly. Try to join more networks, especially those that your out-of-network patients commonly come from. Whenever possible, review and renegotiate payer contracts to pay out more favorably. Update your billing policies and train your staff to work within the constraints of the law. AI-driven, automated RCM software like Claimocity’s can make this transition easier by helping practices stay current with regulations and reduce denials through:
For most providers, out-of-network care brings increased compliance requirements and places extra administrative demands on your staff and existing systems. It seems that the NSA has all but eliminated any financial compensation to make up for the added stress. If your practice relies heavily on out-of-network billing to pay the bills, now is the time to re-evaluate your operation. For many practices, the wise moves may be to expand your network, remain in-network where possible, and strengthen your compliance processes to reduce risk.
Understandably, adding even more complexity to an already complex system can be overwhelming. AI-driven RCM platforms can take some of the pain out of compliance, documentation, and denial management. They integrate with your existing systems to take the guesswork out of RCM and reduce claims denials.
Book a demo to find out more about what automated RCM software can do to help you adapt to running a practice since the implementation of the NSA.
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