The short answer
Anesthesia AR splits into buckets, and each bucket runs on its own clock. Denials caused by registration data, modifier pairs or documentation follow each payer's filing and appeal limits. Out-of-network commercial payments covered by the No Surprises Act follow a federal clock counted in business days: 30 business days from the initial payment or denial to start open negotiation, then 4 business days to start federal independent dispute resolution (IDR) once negotiation ends.
Miss that window and federal IDR is generally closed for that claim. So sort the AR first, then work it in deadline order, closest deadline first.
Why anesthesia AR ages differently
Four things set anesthesia claims apart from the rest of a practice's AR.
The payment is a formula. Medicare pays the sum of base units and time units, multiplied by an anesthesia conversion factor (42 CFR 414.46). One time unit is 15 minutes, and partial units count. For 2026 the national anesthesia conversion factor is $20.4976, or $20.5998 for qualifying APM participants, before the locality adjustment (CY 2026 PFS final rule). A missing start or stop time breaks the math, and a time that conflicts with the anesthesia record invites a cut.
One case can mean two claims. When an anesthesiologist medically directs a CRNA, each bills for the same case and Medicare pays each half of the allowance. The modifiers on the two claims have to agree: QY or QK on the anesthesiologist's claim, QX on the CRNA's (Medicare Claims Processing Manual, ch. 12). A mismatch can hold up both.
The registration data usually isn't yours. Demographics and insurance details usually come from the hospital's or surgery center's record, not your own front desk. A wrong member ID or an outdated plan lands on your claim without anyone on your staff entering it.
Out-of-network claims follow a different clock. Patients rarely choose their anesthesiologist, and an out-of-network anesthesia group can't ask patients to waive the No Surprises Act's protections (45 CFR 149.420(b)). When the plan's payment on those claims is low, the federal dispute process counts its deadlines in business days, not calendar days.
The five buckets of anesthesia AR
Sort before you work. Each bucket has its own test for whether a claim can still be paid, and its own clock.
| Bucket | What it looks like | Still collectible when | Clock |
|---|---|---|---|
| Medical direction pair mismatch | What it looks likeQX on the CRNA's claim with no matching QK or QY on the anesthesiologist's, or modifiers that conflict across the two claims | Still collectible whenA corrected claim goes in inside the payer's filing limit, and the record documents all seven medical direction requirements | ClockPayer filing limit |
| Registration and eligibility | What it looks likeWrong member ID, payer or coverage pulled from the facility's record | Still collectible whenCoverage existed on the date of service, and the claim can be refiled in time | ClockPayer filing limit |
| Time and documentation | What it looks likeMissing or conflicting start and stop times; units cut | Still collectible whenThe anesthesia record supports the time billed | ClockPayer appeal limit |
| Out-of-network payment (No Surprises Act) | What it looks likePaid at or near the plan's qualifying payment amount (QPA), or denied | Still collectible whenOpen negotiation started within 30 business days of the payment or denial | ClockFederal business days |
| Authorization tied to the surgery | What it looks likeAnesthesia denied because the procedure lacked authorization | Still collectible whenThe payer allows retro-authorization or an appeal | ClockPayer policy; check each payer |
Medical direction pairs. Under Medicare's rules, an anesthesiologist directing a case has to meet seven requirements for each patient, from the pre-anesthetic exam to post-anesthesia care, document them, and direct no more than four cases at once (42 CFR 415.110). Work the two claims for a case as one unit. Correcting one without the other leaves the pair mismatched.
Registration and eligibility. Many of these are rejections, not denials. A claim that rejected for a bad member ID never reached the payer, and rejections don't stop the filing clock. Get the corrected details from the facility and refile before the payer's limit passes.
Time and documentation. When a payer cuts units, the appeal is the anesthesia record: start and stop times that match the claim. If the record doesn't support the time billed, the appeal won't either.
Out-of-network payments. The QPA is generally the plan's median contracted rate for the service in that area. A low initial payment on a claim the No Surprises Act covers starts the federal clock in the next section, whatever else you do with the claim. For most old claims, that clock has already run out.
Authorization tied to the surgery. If the procedure wasn't authorized, some payers deny the anesthesia claim too. Whether you can fix it depends on the payer's policy on retro-authorization and appeals, so check each payer before writing these off.
Medicare and Medicare Advantage claims don't belong in the fourth bucket. The No Surprises Act's protections cover group and individual health plans, and people with Medicare, Medicaid or TRICARE are protected another way (CMS No Surprises Act fact sheet). Out-of-network payment from a Medicare Advantage plan is tied to what Original Medicare would pay (42 CFR 422.214). Here is how to dispute Medicare Advantage plans that pay below Medicare.
The No Surprises Act clock
For an out-of-network claim the No Surprises Act covers, the plan's initial payment or denial starts a federal clock. Every step after it is counted in business days, except the last one.
| Step | Deadline |
|---|---|
| Start open negotiation | Within 30 business days, beginning the day you receive the initial payment or notice of denial |
| Open negotiation period | 30 business days |
| Start federal IDR | Within 4 business days after open negotiation ends |
| Payment after an IDR win | Within 30 calendar days of the determination |
Sources: CMS, About Independent Dispute Resolution; 45 CFR 149.510
In states with their own law setting out-of-network payment, claims under state-regulated plans follow the state's process instead. Self-funded employer plans use the federal process unless they have opted into the state's (45 CFR 149.30).
Providers have done well once a dispute reaches a decision. In payment determinations made from July through December 2025, providers, facilities and air ambulance providers prevailed in about 85% (CMS, Federal IDR supplemental background, 2025 Q3–Q4). Read that figure for what it is. It covers every type of provider, not anesthesia alone, and it includes default decisions, where the IDR entity must rule for the only side that submitted an offer and paid its fees. Defaults were 17% of determinations. In decisions that weren't defaults, the provider side won 84%.
The honest part: a missed window doesn't reopen. An out-of-network underpayment from last year is usually long past its 30 business days, so it can't go to federal IDR. The value is in the claims paid in the last few weeks. Find them while the window is still open, and decide whether to negotiate before it closes.
One change is coming. A rule finalized in June 2026 moves open negotiation notices into the federal IDR system and gives the plan until the 15th business day of negotiation to respond. Those parts apply to negotiations that begin 90 days after the government announces the system is ready, which CMS expects in spring 2027 (CMS implementation timeline). Until then, they don't change the clock for your claims.
What to ask before you hire anesthesia AR help
Whether the AR stays in house or goes to an outside team, these seven questions separate a process from a promise. Each one has an answer you can listen for.
How do you sort my AR before you work it?
A good answer sounds like: By bucket and by deadline, with a written list of what is no longer collectible and why.
You can check each claim's filing window yourself before the first call, so you know what that list should contain.
Do you track No Surprises Act deadlines in business days, claim by claim?
A good answer sounds like: Yes, with a dated calendar for each claim, counted from the day the initial payment or denial arrived.
Also ask who starts open negotiation when a claim qualifies: their team, yours, or an outside firm. Whoever does it, the date the clock started belongs on the report.
Do you work the anesthesiologist's and the CRNA's claims for a case together?
A good answer sounds like: Yes, as one unit. Both claims are corrected or appealed together, so the pair matches.
A team that works claims one at a time can fix the CRNA's claim and leave the anesthesiologist's mismatched.
What counts as "recovered" for your fee?
A good answer sounds like: Payer payments on the claims in scope, defined in writing.
Ask how IDR awards and IDR fees are treated, and whether payments that would have arrived anyway are counted. A low percentage on a broad base can cost more than a higher one on a narrow base. Here is what AR recovery typically costs, and what each rate is applied to.
Will you work inside my billing system?
A good answer sounds like: Yes, with no migration. Your data stays where it is.
Ask what access they need, and who on your side approves it.
What does your reporting show?
A good answer sounds like: Dollars recovered, written off and still open, by bucket and by payer.
Ask to see a sample report before you sign anything.
Do you guarantee a collection rate?
A good answer sounds like: No.
Some vendors advertise guaranteed collection rates. Ask what claims the rate is measured on. A rate measured only on the claims a vendor chose to work says little about your backlog.
What it costs
AR recovery is usually priced as a contingency: a percentage of what is recovered. The percentage matters less than what it is applied to, which is why the fourth question above comes first. Whoever you hire, get the fee base in writing before any claims change hands.
Quilven charges 12 to 15 percent of the recovered amount, with no fee on what is not recovered, no setup fee, and month-to-month terms with 30 days' written notice. Where a practice lands in that range depends on claim volume, the age of the inventory and the payer mix. The free audit comes first, and it separates claims that can still be paid from claims that can't before any fee applies. How the work runs is set out on the AR recovery page.
Rules and figures last checked: 29 Oct 2026
