Helping providers and health plans navigate one of healthcare's most complex reimbursement environments — through regulatory expertise, operational excellence, and winning dispute-resolution strategy.
Most firms simply file disputes. Fulcrum is a strategic advisor that understands the entire ecosystem — from provider operations and contract strategy to the payer decision-making process and the federal and state regulatory frameworks that govern dispute resolution. Health systems, physician groups, private equity firms, revenue cycle organizations, and health plans rely on us to build scalable, profitable, compliant NSA programs.
Fulcrum's team includes senior leaders who were among the earliest to build large-scale No Surprises Act compliance and Independent Dispute Resolution programs at national provider organizations — including experience drawn from enterprises such as Envision Healthcare and AmSurg.
Rather than merely reacting to the legislation, our team helped operationalize the processes, governance, analytics, workflows, and financial strategies required to manage the NSA at enterprise scale. We understand both the regulatory intent and the financial realities providers face.
Every dispute begins with determining whether a claim falls under federal or applicable state law. Fulcrum builds governance frameworks that route each dispute down the correct pathway from the outset — minimizing delays and improving recoveries. Select a framework to compare how it works.
Educational summary of framework structures. State rules vary; Fulcrum confirms the governing framework and current requirements for each claim.
Where CMS indicates the Federal IDR process applies, versus a "Bifurcated Process" in which a specified state law or All-Payer Model Agreement may govern the out-of-network rate. Hover a state; click a legend item to isolate it.
Source: CMS, "Chart for Determining the Applicability of the Federal Independent Dispute Resolution (IDR) Process." SSL/APMA information current as of January 11, 2023. Self-insured (ERISA) plans and air-ambulance claims are generally governed by the federal process nationwide, except where a self-insured plan has opted into a permitted state process. The federal IDR process does not apply to Medicare, Medicaid, CHIP, or TRICARE.
A complete operating model for out-of-network reimbursement under the No Surprises Act. Select a phase to expand it.
Successful determinations begin with case selection, evidence, and economics — not the submission deadline. Fulcrum builds strategies, not just filings.
Analytics-driven selection and batch optimization to concentrate effort where the economics justify it.
Economic valuation, payment benchmarking, and expected-value modeling for each candidate dispute.
Market rate and historical award analysis that frame a defensible offer against comparable data.
Structured evidence packages and a persuasive narrative aligned to the factors decision-makers weigh.
Medical-necessity support, clinical justification, and coding integrity that withstand scrutiny.
Pathway, venue, and timing optimization so each dispute moves through the right process efficiently.
Many struggle with the NSA because they never designed an internal operating model for it. Fulcrum builds the governance, workflows, technology, and reporting that turn dispute resolution into a repeatable, high-performing program.
From federal eligibility to award recovery, Fulcrum instruments the entire program. Explore a sample dashboard view.
Illustrative sample dashboards. Fulcrum analytics are built from your actual eligibility, submission, and award data — and can be modeled on your existing Power BI reporting.
The NSA lands hardest on hospital-based and facility-based specialties. Fulcrum supports the full range of provider types and organizations.
Fulcrum differs from traditional arbitration firms: we also advise health plans and TPAs on building compliant, efficient internal NSA programs — bringing the same rigor to either side of the table.
Enterprise NSA programs, federal and state IDR strategy, evidence and case selection, and analytics that maximize appropriate recovery.
We help plans standardize workflows, reduce administrative burden, strengthen documentation, and improve provider engagement — while sharpening compliance and financial performance.
A strategy-and-operations advisor with deep NSA specialization — combining former national program leadership, federal and state expertise, and analytics-driven execution.
Senior leaders who ran enterprise NSA programs.
Helped operationalize the law at national scale.
Fluency across every dispute-resolution pathway.
Data behind case selection, valuation & evidence.
We design the operating model, not just advise.
Healthcare reimbursement is our entire focus.
Scalable operating models built to grow.
Built around the realities providers face.
Credible experience on both sides of the table.
Board-ready visibility into program performance.
Repeatable governance and workflow at any size.
Federal and multi-state coverage, coast to coast.
NSA updates, IDR strategy guides, and executive insights — a resource center built for leaders navigating out-of-network reimbursement.
We build strategic capability and sustainable programs. The outcomes below reflect the kind of operational transformation clients pursue — not a guarantee of arbitration results.
Faster, more consistent movement of disputes from eligibility through determination.
Increased organizational readiness for federal and state compliance obligations.
Improved consistency in case selection and evidence development across teams.
Enhanced governance and board-level visibility into program performance.
Programs designed to support organizational and transaction-driven growth.
Better alignment between legal, clinical, revenue cycle, and contracting teams.
Whether you are establishing an enterprise-wide NSA program, optimizing IDR performance, or strengthening compliance across federal and state frameworks, Fulcrum delivers the strategic expertise, operational discipline, and reimbursement insight to build a sustainable, high-performing program.