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.

If you’ve been paying attention (which we’re sure you have), you may have noticed that the Centers for Medicare & Medicaid Services (CMS) has been doing quite a bit of work surrounding the No Surprises Act (NSA) and Transparency in Coverage (TiC) rulings that were scheduled to go into effect during the 2022 plan year.

While the road to compliance has been fraught with complaints and lawsuits, CMS and the other NSA implementing government agencies have done their best to take a measured approach to statute implementations, including pushing back the original proposed deadlines that many felt were impractical.

Of those latest rulings, there are a few of particular importance.

National Provider Directory

Balance billing and Independent Dispute Resolution have been at the forefront of the NSA requirements, and while there is currently no national standard for Advanced Explanation of Benefits (AEOB) and provider directory rules, many are beginning to recognize the importance of and potential difficulty towards implementing these requirements. As such, CMS is taking steps towards creating a national provider directory.

Traditionally, provider directories are maintained by individual health plans. These directories include a list of providers in their network, as well as other useful information (e.g., address, full name, phone number, etc.). But thanks to the COVID-19 pandemic, a new need to exchange and access electronic healthcare data surfaced.

A national provider directory will significantly improve the data exchange that currently exists with interoperable technology. Meaning: patients will be able to look up and see which providers are in their network according to their health insurance plan, region, and needs.

The goal is to connect the NSA requirement to have accurate, regularly updated and verified directories. CMS has volunteered to underwrite the technical lift needed to build out this directory, and providers will be responsible for consistently updating information.

Advanced Explanation of Benefits

NSA has also introduced a requirement for AEOBs (applicable to all services, in- and out-of-network, by providers and facilities). AEOBs must be provided whenever an appointment is made for services and also whenever requested by the member, even without an appointment.

For every scheduled service and upon member request, the payer must provide the member with an AEOB that includes:

  • Whether the provider or facility is a participating provider, or in-network (INN), and the contracted rate for the item or service
  • If the provider or facility is out-of-network (OON), description on how to find information on INN providers
  • Good faith estimates for each of the following:
  • Provider billed charges (sent by the provider)
  • Amount the payer is responsible for paying
  • Member’s cost-share responsibility
  • Amount the member has incurred toward meeting deductibles and OOP maximums
  • A disclaimer that coverage is subject to medical management, if applicable
  • Any other applicable information or disclaimer

The long and short of it: Providers must ask patients whether they are enrolled in a group health plan and, if so, provide an estimate of the expected charges to the patient’s insurer. After receiving the estimate, plans must provide an AEOB to the plan participant that informs them whether the provider/facility is INN, of what the plan will pay, and any cost-sharing requirements.

Overwhelming, right?

While standards around AEOB requirements implementation are still in the future, many health organizations are working towards developing standards surrounding data interoperability for AEOB requirements. CMS is also creating a new form for AEOBs to streamline the information-gathering process of estimated costs to ensure greater cost transparency for patients, especially from ONN providers.

Independent Dispute Resolution

Simply put, the independent dispute resolution (IDR) procedure is tricky.

The IDR ruling within the NSA oversees the mediation process between payers and OON providers when they cannot come to an agreement on reimbursement. These new rules ensure excessive out-of-pocket costs are restricted and emergency services are covered regardless of whether an INN provider.

While the IDR process has been operationalized since January 2022, CMS is still working on process improvements, such as considering more than just the qualifying payment amount (QPA) when determining reimbursement amounts, including a notice of offer form, and introducing process initiation screening questions.

The wrap up

These improvements are only the beginning of many solutions to come for current and future policies and the regulatory process as a whole. Bottom line: legislation isn’t going anywhere any time soon. Both the NSA and TiC legislation, as well as their corresponding rulings and updates, will have long-term implications across the healthcare ecosystem.

But don’t think of compliance as just checking a box. These mandates serve as an opportunity to develop innovation solutions that leverage the current healthcare industry in creative ways.

Interested in how Zelis can help you tackle the pain points of regulatory compliance? Connect with us.