No Surprises Here: Exploring Future Out-of-Network Strategies
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.
A hot topic for payers and providers since late 2020, the No Surprises Act (NSA) should be anything but a surprise. But there is still quite a bit of confusion surrounding the specifics, and many payers report little to no change to their current processes.
During a recent webinar with industry expert Matthew Albright, Chief Legislative Affairs Officer at Zelis, participants were asked how much their strategy changed after the implementation of the NSA and Transparency in Coverage rule (TiC).
The results were, for lack of a better word, surprising.
40% shared that no changes had been made, and none (yes, 0%) of the respondents’ organizations had completed all the changes required.
In the webinar, Matthew, along with thought leaders from advisory firm Aite-Novarica, further discusses where the NSA stands just over half a year into its implementation, what steps lie ahead for payers, industry trends, legislative activity affecting out-of-network claims, and more.
As always, we’ll discuss the highlights below, and you can listen to the full webinar here.
According to Matthew, two of the biggest challenges within current NSA implementations are the functionality of the federal Independent Dispute Resolution (IDR) portal and the complexity of the process as a whole.
The problem is this.
In the Economic Impact and Paperwork Burden analysis for the Interim Final Rule, HHS (the Departments) estimated roughly 17K claims submitted to IDR annually. Instead, according to a recent AHIP report, in the first two months of 2022, the NSA prevented more than 2M potential surprise medical bills.
As of mid September, there were roughly 75K IDR submissions but only 11 Certified IDR Entities (aka the people who evaluate and determine the winners of disputes). Three of which have recently stated they are no longer able to accept future IDR submissions.
If you do the math, approximately 12M surprise bills will be avoided in 2022.
Even if only a fraction of these claims are ultimately disputed through IDR, it still far exceeds the original estimate. The only option to handle the demand would be a complete rehaul of the overloaded system.
In addition to portal problems, eight lawsuits have been filed in the past six months. Seven of those regard the arbitration methodology providers and payers must use to determine the reimbursement amount on NSA claims.
And that’s not all.
On August 19, 2022, the Departments issued their final rule titled “Requirements Related to Surprise Billing: Final Rules.”
These rules finalize requirements under the July 2021 interim final rules, which relate to the information group health plans and health insurance issuers that offer group or individual health insurance coverage must share about qualifying payment amounts (QPA).
In other words, this rule focuses on the reimbursement process for both payers and providers. Matthew Albright discusses the overview in a recent video. Watch it here.
“Networks are under scrutiny now to bring value.” — Lisa LaMaster, Zelis VP of Business OON Solutions
While the NSA is certainly a significant factor, it’s hardly the only one steering out-of-network strategy. Rather, payers need to look beyond the NSA (and healthcare in general) to see the components directly impacting pricing (e.g., increasing costs, shrinking margins, labor shortages, impending recession).
Just take a look at some of the current economic issues we’re facing, like the great resignation. Or dive into current industry trends, like the focus on mental health, wellness, and benefit plan design. Consider the implications networks, reimbursement, benefits, and member empowerment will have, as well.
To succeed, each of these additional factors, as well as individual needs, must be taken into account when developing your pricing strategy.
Patient and member engagement has evolved from passive engagement to an integrated partnership.
Consumers are better informed and more actively engaged in their medical care than ever. And there’s no doubt in anyone’s minds that technology is a key catalyst in driving this increased involvement.
But that doesn’t mean they have all the answers.
While the NSA has eliminated hidden fees and allowed for price and plan comparison, there is still a lot of confusion surrounding what qualifies as a good plan and the importance of choosing a plan tailored to the individual.
Take a look at what drives value, what connects with member needs. Ask yourself, what’s possible? How can we leverage our technology and NSA strategy to drive empowerment and education?
The wrap up
Healthcare and health insurance have undergone significant changes in the last few years. To keep up, you must remain agile and willing to adjust to the ever-changing needs of members and providers.
A good first step? Automation.
To learn more about NSA and TiC requirements, as well as the Final Rules and their impact on payers, plans, providers, and members, visit our regularly updated Information Hub here.
Looking for more IDR info? Matthew Albright recently joined the Future Healthcare Today podcast to help sort out the potential impacts of the final rules on the IDR process. Take a listen here.
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