As No Surprises Act rules tighten, Zelis expands AI role in dispute process

Zelis is positioning artificial intelligence as a solution to growing administrative burdens under the No Surprises Act's independent dispute resolution process. But the company's latest product launch also raises broader questions about the growing role of algorithmic decision-making in reimbursement disputes, particularly as Zelis faces antitrust allegations over its influence on out-of-network payment rates.

Zelis announced today a new AI-native tool specifically designed to help payers manage growing dispute volumes and new compliance requirements. The product, dubbed Zelis NSA Claim Advantage, seeks to unify automation, predictive intelligence and embedded expert validation into a single workflow across IDR functions, including open negotiation, dispute prevention and IDR resolution.

The new platform arrives as federal regulators implement sweeping changes intended to improve transparency and efficiency in the arbitration system.

CMS released a final rule in May that essentially overhauled dispute resolution under the No Surprises Act. The changes sought to address some of the most significant bottlenecks in the IDR process, such as claim eligibility and lack of meaningful open negotiations.

The rule comes with new deadlines payers will have to follow in the coming months or potentially forfeit their say in the IDR process. That includes getting information requested by arbitrators within five days and formalizing the 30-business-day period for open negotiations.

Payers will also have to better communicate claim eligibility for the IDR process, which has been a sticking point for providers who say payers are sitting on the information. Finally, the rule changes how payers send remittance advice to providers outside their networks. Payers must now include claim adjustment reason codes and remittance advice remark codes.

While promising IDR process efficiencies, this new rule adds complexity to the IDR process, said Jim Bridges, president of price optimization at Zelis. Payers are also generally using disparate tools and manual workflows to navigate the volume-heavy process.

Zelis says the platform will streamline IDR navigation for payers using AI. The company has already established strong leverage within the complex IDR landscape. Zelis says it serves more than 750 payers, including the nation's largest health insurers. That reach gives the company access to an enormous volume of claims and arbitration data, potentially creating competitive advantages that smaller market participants cannot replicate.

The company is betting on predictive intelligence and automation to deliver this type of data to payers to provide real-time insights into their IDR position and help inform negotiation strategies. The new product specifically targets key workflows, like intake, documentation, alerts and dispute escalation, and provides analytics for qualifying payment amount calculations.

Zelis also promises payers insights into the behavior and patterns of certified IDR entities and healthcare providers, which the company said they can use to inform settlement strategies and create customized case submissions.

"It combines AI-native automation, data-driven intelligence and human review across every step in the journey to identify risks earlier, reduce avoidable disputes and replace the guesswork with predictable outcomes," Bridges said in the announcement.

While insurers may welcome tools that automate compliance and dispute management, providers and policy observers are likely to scrutinize whether AI-driven negotiation strategies could further tilt an already contentious process toward large payers with access to extensive claims data.

A California-based medical group has already accused Zelis of forcing it to accept suppressed payment rates in an antitrust lawsuit that also names Aetna, Cigna, Elevance, Humana and UnitedHealth Group. The lawsuit alleges that Zelis and several major insurers used shared reimbursement data to suppress out-of-network payment rates and reduce competition using a repricing tool.

Zelis has denied wrongdoing, maintaining that it operates in full compliance with relevant laws and regulations.

Jacqueline LaPointe is an Executive Editor at Xtelligent Healthcare Media, covering revenue cycle management, healthcare payers, health policy and health IT since 2016.