Einstein, Knowledge, and State Legislation

“Information is not knowledge,” Einstein famously said.

Today, we are awash in data and information. But information is useless if we don’t have the ability to apply that information to our lives and businesses, and derive some benefit. Only then does information become knowledge.

At Zelis, we pride ourselves on our situational knowledge; that is, being aware of the environment and trends of our industry and being able to know and predict our clients’ needs. On the legislative level, situational knowledge means going beyond just tracking laws and regulations; it means using the information we track to create better situations for you, our client.

With that in mind, let’s talk about how Zelis takes legislative information and applies it to improve your business.

Claim Payments and Remittance Advice
At least six states have recently adopted provisions around how and when payers must use EFT and electronic remittance advice, and more states propose similar legislation each year. In Oregon and Maryland, payment rules passed in the last two years prohibit payers from automatically enrolling providers in virtual card payments (and any payment process with fees) without their permission.

While many vendors require providers to “opt out” of automatic enrollment, Zelis Payments has believed − since its inception − that providers should have a choice of how they want payments and data delivered. Zelis’ opt-in model is built on the premise that providers must consent to taking the payment. Even further, our enrollment sales team uses a consultative methodology to educate providers on their options, leading to greater acceptance and provider satisfaction.

At the federal level, the Centers for Medicare & Medicaid Services (CMS) recently announced its plan to launch an audit program that would check health plans’ compliance with standards and operating rules for electronic transactions, including EFT and electronic remittance advice. Read more here

With state laws on top of federal requirements and ever-changing banking requirements, compliance with payment rules is getting more complicated, increasing the risk to payers. Payers can be assured that Zelis is vigilant of the intricacies of payment rules and is constantly confirming conformance with those rules.

Claim Settlements
After the 2017 sessions, 30 states have prohibitions or restrictions on an out-of-network provider’s ability to balance bill a member in emergency and/or non-emergency situations. Zelis’ knowledge of these diverse state laws helps us negotiate with out-of-network providers and protect members through our Reference Based Pricing solutions and Payment Integrity products.

But most state laws don’t apply to self-funded plans because of the ERISA exemption. Nevertheless, Zelis has combed through these state laws in order to obtain some leverage in protecting members of our client ERISA plans. For instance, three of the eight states that passed balance billing laws in 2017 included notification requirements that providers must give to the patient about non-emergency services provided by out-of-network providers. Those notification requirements apply regardless of who the payer is.

State laws alone don’t protect the plan or the member. Payers must have an appeals management process that leverages state regulations to protect members from surprise billing. Zelis provides that process, helping health plans achieve their member hold-harmless initiatives.

Provider Network Directories
An appropriate motto for Zelis’ approach to state provider directory laws is “we’re all in this together.”

Since California SB 137 in 2015, compliance with state directory laws has become a major focus for payers. In 2016, Maryland and Georgia passed burdensome directory laws, and, in 2017, Hawaii and Illinois joined them. There are now 30 states with provider directory laws or regulations.

Although Zelis is not an insurer or administrator, we’re dedicated to playing an active role in supporting our payer clients to meet these state requirements. Our focus is on both provider-facing activity for our direct provider contracts as well as provider-facing activity from our network partners. With this focus, Zelis is committed to deploying resources and solutions to support you.

Underlying the many facets of the state mandates – including data maintenance requirements, notifications, provider contract language, and required data fields – the crux of these laws is the accuracy of the provider data. State governments are keenly focused on complaints and audits that point to unreliable directories and are targeting their enforcement efforts toward insurers with inaccurate data.

Identification of accurate data will continue to be a priority for Zelis. As an example, Zelis’ Provider360 data quality reporting and monitoring platform provides a continuous review process that is not found in other review methods in the market. For more information on our Provider360 platform, refer to Provider360 article in this edition of The Z Factor.

Zelis is dedicated to collaborating with our clients to implement the best possible solutions and make continual improvement in the data we provide.

Even knowledge is not enough
One of Einstein’s underlying ideas was that knowledge and intellect were not enough; true genius also required creativity. At Zelis, our legislative knowledge informs our creativity which is zealously devoted to creating new processes and solutions so that clients can spend less time thinking about laws, and more time thinking about healthcare.