ZanexMed — Revenue Cycle Management

Out-of-Network Claim Negotiation
Services That Recover Fair Payment

Expert out-of-network reimbursement negotiation for hospitals, freestanding ERs, and specialty providers across the United States. We fight payer underpayments so your practice receives the fair reimbursement it deserves.

$50M+
Revenue Recovered
for Clients
80%+
Claims Processed
via MultiPlan
48hr
Negotiation
Response Time
32+
Specialties
Served
Introduction

Out-of-Network Claim Negotiation Services That Maximize Your OON Reimbursement

When a patient receives care from a provider outside their insurance network, the payer’s payment obligation is not governed by a pre-negotiated contract. That creates both a challenge and an opportunity. The challenge: payers routinely underpay out-of-network claims — sometimes offering as little as 30–40 cents on the dollar — using third-party repricing vendors and aggressive usual, customary, and reasonable (UCR) rate calculations to suppress reimbursement.

The opportunity: out-of-network claims are negotiable. With the right data, the right documentation, and the right negotiation strategy, providers can recover significantly more than payers initially offer. ZanexMed’s professional out-of-network negotiation services exist precisely for this purpose — to challenge low settlement offers, engage payer outreach directly, and pursue maximum OON reimbursement on your behalf.

Our team brings decades of combined RCM experience, proprietary OON databases, and deep familiarity with how repricing vendors like MultiPlan (now Claritev) operate. We handle pre-payment and post-payment negotiations, manage the entire claims process from review to settlement, and ensure your practice never walks away from money it is legally and contractually entitled to receive.

Industry Reality

Industry data shows that MultiPlan alone processes over 80% of out-of-network claims in the United States. These repricing vendors apply complex algorithms and employer benefit limits to suppress payouts — often without providers realizing it. ZanexMed knows these tactics inside out and counters them systematically on every eligible claim.

At a Glance
Pre + Post
Payment negotiation coverage
NSA Compliant
No Surprises Act aligned
Data-Driven
Proprietary OON database
$50M+
Revenue recovered for clients
IDR Ready
Federal arbitration when needed
Definition

What Is Out-of-Network Claim Negotiation in Healthcare Billing?

Out-of-network claim negotiation is the process of engaging payers — and their repricing intermediaries — to recover a fair, market-rate reimbursement for services rendered to patients whose insurance plan did not include the provider in its contracted network. Unlike in-network claims where reimbursement is governed by a pre-set contract, OON reimbursement is determined through negotiation, and payers have every incentive to settle as low as possible.

A dedicated out-of-network negotiation service ensures that providers are not passively accepting whatever the payer initially offers. Instead, every settlement offer is evaluated against benchmark rate comparisons, regional UCR data, and payer-specific reimbursement behavior — and challenged when it falls short of fair market value.

The Two Stages of OON Negotiation — Pre-Payment and Post-Payment

ZanexMed approaches OON claim negotiation across both stages of the payment lifecycle — a dual-stage model that ensures no eligible claim is left unexamined.

StageWhat It CoversZanexMed Action
Pre-Payment Negotiation Insurer sends a settlement offer before paying the claim — often via a repricing vendor such as MultiPlan/Claritev. Provider must accept, counter, or reject. We review every settlement offer against UCR benchmarks, counter low offers with documentation, and negotiate to a higher payment before the claim is finalized.
Post-Payment Negotiation Claim was already paid at a repriced or reduced rate. Provider disputes the low payment after the fact. We reopen the claim, analyze the repricing methodology, challenge the payer’s calculation with clinical and billing data, and pursue additional payment through the appeal and reconsideration process.

How the No Surprises Act Affects Out-of-Network Billing

The No Surprises Act (NSA), effective January 1, 2022, introduced significant changes to how out-of-network billing works in the United States — particularly for emergency services. Under the NSA, patients receiving emergency care at out-of-network facilities — including freestanding emergency rooms — cannot be billed more than their in-network cost-sharing amount. This shifts the financial dispute from the patient to the payer and provider.

For providers, this means OON payment disagreements now go through the federal Independent Dispute Resolution (IDR) process when direct negotiation fails. The CMS No Surprises Act dispute resolution portal governs this process. ZanexMed manages both the pre-IDR negotiation phase and the full IDR filing process on your behalf — see our IDR billing services for a complete overview.

Important: Providers who do not engage in proactive OON negotiation often accept underpayments passively — turning a recoverable underpaid claim into a permanent revenue leakage event. ZanexMed exists to prevent exactly that.

Our Process

ZanexMed’s Out-of-Network Claims Negotiation Process — Step by Step

Our out-of-network negotiation workflow is built for thoroughness and speed. Every eligible OON claim goes through a structured, documented process that ensures maximum reimbursement and full compliance with federal and state billing regulations.

1
Claim Review and Eligibility Assessment
Our team reviews every claim to confirm OON status, identify the repricing vendor involved, and assess the payment against benchmark rate comparisons and regional UCR rates. Claims are flagged for negotiation based on underpayment threshold — typically any claim paid below a defined percentage of billed charges or fair market value benchmarks.
2
Documentation Support and Coding Audit
Before engaging the payer, we conduct a documentation support and coding audit — verifying that the claim is coded accurately, that medical necessity documentation is complete, and that all supporting records (clinical notes, operative reports, referral documentation) are in order. A poorly documented claim cannot be successfully negotiated.
3
Payer Outreach and Negotiation
We initiate direct payer outreach through payer negotiation portals, phone, and written correspondence — presenting our benchmark data, clinical justification, and the provider’s negotiation position. For claims involving repricing vendors like MultiPlan, we engage the vendor directly using our proprietary OON database and negotiation best practices developed over years of claims experience.
4
Offer Evaluation and Settlement
Every settlement offer received is evaluated against our benchmark thresholds. If the offer meets our recovery target for that claim, we accept and process the settlement. If not, we counter with a documented position and continue negotiating. We never accept a settlement without comparing it to fair market value data — ensuring providers are not leaving money on the table through uninformed settlements.
5
Appeal Escalation Process
When initial negotiation does not yield an acceptable settlement, we escalate through the appeal and reconsideration process — filing formal written appeals with clinical and billing documentation, citing payer contractual obligations, and referencing applicable state and federal billing compliance guidelines. We track every escalated claim with a defined follow-up schedule.
6
Arbitration and Dispute Resolution (IDR)
For claims covered under the No Surprises Act where direct negotiation has not resolved the dispute, ZanexMed manages the full federal IDR filing process — preparing the arbitration case, submitting all required documentation, and representing your practice through to the final determination. Use our free IDR Claim Checker tool to instantly assess whether your claim qualifies.
7
Payment Posting and Follow-Up
Once a negotiated settlement is reached, our team handles payment posting and follow-up — confirming that payment is received at the negotiated amount, reconciling against the claim, and flagging any discrepancy between the agreed settlement and actual payment for immediate resolution.
Specialties

Out-of-Network Negotiation Across All Major Specialties

OON claim negotiation challenges vary significantly by specialty. ZanexMed brings specialty-specific expertise to every negotiation — understanding the unique coding requirements, payer behaviors, and documentation standards that affect OON reimbursement in each field.

Emergency Room OON Negotiation
The highest-volume OON billing environment in U.S. healthcare. We specialize in ER and freestanding emergency room OON negotiation — including No Surprises Act compliance and IDR escalation.
Hospital Billing Negotiation
Complex inpatient and outpatient claims with high dollar values. Our team handles facility fee negotiation, DRG-based payment disputes, and ancillary service OON settlement.
Radiology OON Claims
Radiology is one of the most frequently out-of-network specialties in the U.S. We negotiate technical and professional component payments — including imaging center facility fees.
Anesthesiology OON Claims
Anesthesiologists are frequently OON even when the facility is in-network — creating high underpayment risk. We negotiate time-based anesthesia unit payments and fight low UCR offers from payers.
Surgical Claim Negotiation
High-value surgical claims deserve aggressive negotiation. We handle pre-payment and post-payment OON settlement for all surgical specialties — including orthopedics, neurosurgery, and general surgery.
Behavioral Health OON Billing
Mental health and substance use disorder OON claims require parity law compliance knowledge. ZanexMed negotiates behavioral health OON payments with parity act documentation support.
Patient Protections

OON Negotiation Protects Your Patients — Not Just Your Revenue

Effective out-of-network claim negotiation is not just about the provider’s bottom line — it directly protects your patients from unexpected financial exposure. Under the No Surprises Act and applicable state balance billing limitations, patients cannot be billed the difference between the provider’s billed charges and what the insurer pays on OON emergency claims. The financial gap is between the provider and the payer — not the provider and the patient.

This means the stakes of a poorly negotiated OON claim fall entirely on your practice. Every dollar the payer underpays and goes unchallenged is a dollar your practice absorbs. ZanexMed’s OON negotiation services ensure that the full burden of payer underpayment never becomes your practice’s permanent loss.

What Is Balance Billing — and How Does the NSA Limit It?

Balance billing occurs when a provider bills a patient for the difference between billed charges and the amount paid by the insurer. In most emergency OON scenarios, the No Surprises Act prohibits this practice — protecting patients from surprise bills while simultaneously establishing a federal mechanism for providers to dispute the payer’s payment through Independent Dispute Resolution.

ZanexMed ensures your practice’s OON billing processes are fully aligned with federal and state billing compliance requirements — including compliance with ERISA for employer-sponsored plans and applicable state surprise billing laws — so your practice is always protected from regulatory exposure.

Patient Billing Transparency

ZanexMed supports patient billing transparency at every step. We help practices implement clear patient communication about OON status, cost-sharing expectations, and the protections available under the No Surprises Act — building patient trust while protecting the practice financially.

Why ZanexMed

Why Providers Choose ZanexMed for Out-of-Network Reimbursement Negotiation

ZanexMed is a full-service revenue cycle management company with deep specialization in the most challenging OON billing scenarios in U.S. healthcare — including freestanding emergency rooms, high-complexity surgical cases, and NSA-covered services. Our data-driven negotiation strategies have recovered millions of dollars for clients who were previously accepting whatever payers offered without challenge.

$50M+
Revenue Recovered
Millions recovered in underpaid OON claims for practices that switched to ZanexMed from passive billing arrangements.
Dual
Stage Coverage
We handle both pre-payment negotiation and post-payment appeal — no eligible claim stage is left unaddressed.
Data
Driven Strategy
Every negotiation is backed by our proprietary OON database, UCR benchmarks, and OON reimbursement analytics — not guesswork.
NSA
IDR Expertise
We manage the complete federal IDR process from initiation through arbitration for claims covered under the No Surprises Act.
100%
HIPAA Compliant
All negotiation activities, document handling, and payer communication follow strict HIPAA compliance protocols throughout.
32+
Specialties Served
From freestanding ERs to behavioral health and surgical practices — our team understands the specific OON dynamics of every specialty we serve.
Related Services

ZanexMed Revenue Cycle Services Connected to OON Negotiation

Out-of-network claim negotiation does not operate in isolation — it is one part of a complete revenue cycle strategy. Below are the ZanexMed services most directly connected to OON outcomes:

IDR Billing Services
When OON negotiation reaches an impasse, our IDR team files and manages the full federal arbitration process under the No Surprises Act.
Denial Management
OON claims that are formally denied — rather than underpaid — require our denial management team to appeal and recover through the standard claims process.
A/R Management
Unresolved OON claims age in your receivables. Our AR management team ensures that no negotiated or pending OON claim sits idle in the aging bucket.
Medical Coding Services
Accurate coding is the foundation of any successful OON negotiation. Our certified coders ensure every claim is code-compliant before negotiation begins.
Credentialing Services
Proper payer credentialing determines in-network vs. OON status. Our credentialing team ensures providers are enrolled where it makes the most financial sense.
Revenue Leakage Estimator
Find out how much underpaid OON claims are costing your practice annually with our free revenue leakage calculator — instant estimate, no sign-up.
FAQ

Frequently Asked Questions About Out-of-Network Claim Negotiation

Out-of-network claim negotiation is the process of engaging payers and their repricing intermediaries to recover a fair, market-rate payment for OON services — rather than passively accepting whatever the insurer initially offers. It matters because payers routinely underpay OON claims using complex repricing algorithms. Without active negotiation, providers absorb the entire underpayment as permanent revenue loss. ZanexMed’s negotiation team challenges every underpaid OON claim to maximize recovery through both pre-payment and post-payment negotiation strategies.
The No Surprises Act, effective January 2022, prohibits providers from balance billing patients for most OON emergency services — including services at freestanding emergency rooms. It limits what patients pay to their in-network cost-sharing amounts, and establishes the federal Independent Dispute Resolution (IDR) process for providers and payers to resolve payment disagreements without involving the patient. ZanexMed manages both the pre-IDR negotiation phase and the complete IDR filing process when direct negotiation fails.
OON negotiation is the direct bilateral process between the provider (or their representative) and the payer — attempting to reach a mutually acceptable settlement through offers, counteroffers, and documentation. IDR is a federal arbitration process established by the No Surprises Act that is initiated when the 30-day open negotiation period fails to produce an agreement. In IDR, an independent, certified arbitrator selects between the two parties’ final offers. ZanexMed handles both — starting with negotiation and escalating to IDR when necessary. Use our free IDR Claim Checker to see if your claim qualifies.
MultiPlan (now operating as Claritev) processes over 80% of OON claims in the United States and uses proprietary repricing algorithms to reduce payouts on behalf of payers. ZanexMed engages MultiPlan/Claritev directly through their negotiation portals — submitting counter-offers backed by our proprietary OON database, regional UCR benchmarks, and medical necessity documentation. Our team understands the specific tactics and terminology these vendors use and counters them with data-driven negotiation strategies that consistently deliver higher settlement amounts.
Yes. Post-payment negotiation is one of ZanexMed’s core specialties. If a claim was already paid at an underpayment level — whether through repricing, incorrect UCR application, or payer miscalculation — our team can reopen the claim and pursue additional payment through the appeal and reconsideration process. This is subject to payer-specific timely filing windows for post-payment disputes, so acting quickly is important. Contact us to review your existing OON payment history for recovery opportunities.
Yes — and this is one of ZanexMed’s most differentiated service areas. Freestanding ER OON billing is among the most complex in U.S. healthcare, combining high claim values, No Surprises Act compliance requirements, frequent encounters with repricing vendors, and the need for IDR expertise when negotiations fail. ZanexMed was built with freestanding ER clients in mind. Our team handles the complete OON negotiation and IDR lifecycle for freestanding ERs — from initial payer outreach through final arbitration settlement.

Stop Accepting Less Than You’re Owed on OON Claims

ZanexMed’s out-of-network negotiation specialists are ready to review your current OON reimbursement rates, identify underpaid claims, and start recovering the revenue your practice deserves. No obligation, no cost for the initial review.

Talk to a Negotiation Specialist Check IDR Eligibility Free
+1 (833) 327-0541  |  info@zanexmed.com  |  30 N Gould St, Sheridan, WY 82801