Kaitlin Howard

By Kaitlin Howard

Kaitlin Howard is a researcher and writer producing insightful content across the healthcare revenue cycle. She has written and produced content for Zelis, Waystar, and Recondo Technology, as well as agencies. With a B.A. in English and Writing from University of Denver, Kaitlin stays current on market updates on claims management and healthcare payments, publishing a regular educational blog series on industry trends and Zelis offerings.

In the third part of our payer/provider series, Zelis Director of Business Solutions Leah Silver joins Brian Zimmerman with Becker’s Hospital Review to highlight the latest NSA and TiC rulings within the healthcare industry. In this episode, we’ll discuss:

  • A No Surprises Act and Transparency in Coverage overview
  • Common misconceptions regarding new rulings
  • Best practices for out-of-network claims

As always, we’ll discuss the highlights below, but you can also listen to the full podcast here:

The No Surprises Act and Transparency in Coverage Rule

The No Surprises Act (NSA) seeks to protect patients from surprise medical bills and prohibits balance billing for certain out-of-network care. The Transparency in Coverage Rule (TiC) provides consumers better insight into the cost of services before obtaining care and receiving a bill.

The goal? Minimizing balance billing to ensure patients are protected throughout the entire process.

But even with all those moving parts, as a payer right now, you’re safe.

The initial impacts of the law as of January 1, as well as the expected enforcement, are primarily focused on the provider (e.g. ensuring good faith estimates).

Common Misconceptions

NSA and TiC rulings are constantly changing. How we think about it now versus six months and twelve months down the line will be entirely different. Lawmakers, payers, providers, and consumers are just now starting to understand the complexity and nuance of the ruling. The key is to be amenable to the change, understand the direct impact on the member, and aim to drive down the cost of healthcare across the board.

Even more important? Partner with someone scalable.

Out-of-Network Claims

Payers must create a solid pricing plan for provider network claims and update provider directories consistently.

Let’s set the scene.

A member chooses a provider listed as in-network on their insurance’s directory. When the bill finally comes, however, that hospital is now listed as out-of-network.

It happens more often than we’d all like to admit. But with the latest NSA and TiC rulings, surprise billing is taking a harsh hit.

If a payer lacks the infrastructure necessary to regularly update their directory, those new laws are going to make sure quoted rates are still honored (even if providers were originally listed as in-network rather).

The Wrap Up

Bottom line? Consider the member. Protect the member at all costs. Take into account their typical processes for healthcare when creating opportunities for innovation.

Seamlessness is king. Align yourself with a partner that allows you to create a healthcare journey that ties into the way members live.

If you’re interested in finding out how Zelis can support your organization’s innovation efforts, click here.