The stakes surrounding out-of-network (OON) billing support have never been higher. Member dissatisfaction, administrative burden and costly surprise billing disputes are taking a toll on payers, members and providers alike.
Yet for payers, this isn’t simply a financial issue. It’s a trust issue.
The growing frustration among members isn’t entirely without cause. Nearly half (45%) of insured, working-age adults in the U.S. received a medical bill or copayment in the past year for a service they believed should have been covered by their insurance. Even more concerning: About 61% of U.S. adults say they are either very or somewhat worried about being able to afford unexpected medical bills for themselves or their families.
As expectations around healthcare price transparency and empathy grow, a new model of OON billing is taking shape — one that’s payer-driven, provider-conscious and member-centric.
Let’s explore what this model looks like in practice and how forward-thinking payers are reimagining medical billing support to reduce friction, build loyalty and deliver meaningful value.
Why Member-Centric Billing Support Matters on Out-of-Network Claims
For decades, medical billing has been treated as a transactional back-office function —complex, reactive and often disconnected from the member experience. But as healthcare consumers become more informed and vocal, payers are under pressure to deliver not just accurate bills, but empathetic, transparent support.
Member-centric billing support goes beyond resolving errors or answering questions. It’s about recognizing that billing isn’t just about dollars and codes — it’s about trust and clarity. A member-centric model prioritizes education, proactive communication and personalized guidance. It meets members where they are, helping them understand what they owe, why they owe it and how to resolve discrepancies without unnecessary stress.
This shift is being accelerated by industry-wide trends. Healthcare price transparency and surprise billing mandates have created increased scrutiny and potential arbitration costs for payers. Meanwhile, consumer expectations continue to rise — members want billing to be as seamless and intuitive as other parts of their healthcare journey.
The future of payer-member relationships will be defined by proactive, personalized engagement. Real-time transparency, integrated claim resolution and expert support are no longer “nice-to-haves”— they’re essential components of a modern billing experience.
What a Modern Out-of-Network Billing Support Model Looks Like
Traditional medical billing support often leaves members to fend for themselves —confused by codes, overwhelmed by costs and unsure where to turn. But a modern model reimagines this experience by blending technology, expertise and empathy to meet members where they are.
At its core, this model is built on four pillars:
Communicate: Provide Clarity Through Member-Centric Billing
Proactive, multi-channel outreach creates a sense of partnership and trust. It also ensures members know help is available before bills arrive.
For example, one bill navigator helped a member reduce a medical bill by $155,000.
That kind of consistent communication builds confidence and reduces anxiety.
Educate: Reduce Confusion on Out-of-Network Claims
Guide members through the complexities of OON billing, benefit structures and claims resolution. When members understand what they’re being charged and why, they’re empowered to make informed decisions.
This level of detail is important in helping members through complex medical bills. By helping them understand the benefit structure, they can hopefully avoid costly claims and charges in the future – and payers can build a long-lasting relationship with the member.
Investigate & Resolve: Claims Resolution Support That Builds Confidence
Behind every confusing bill is a story — sometimes of misapplied benefits, incorrect provider coding or claims processed in error. A modern support model digs into these details, identifies discrepancies and advocates for corrections.
It’s not uncommon for providers to send bills to members when payments from health plans are delayed or don’t meet expectations—sometimes simply because a piece of documentation is missing. The result? Members are caught in the middle, unsure why they’re being billed and uncertain about how to resolve the issue. This confusion can turn into a stressful experience, underscoring the need for clear communication and proactive support that helps members understand what’s happening and guides them through their next steps.
“Without having the provider’s contact information, I had to research and find the facility’s information and who to contact within the facility,” Tasha shared of a recent experience. “It took multiple phone calls. Some of the reps and I were very familiar with each other.”
That level of persistence and problem-solving is what turns frustration into relief.
Negotiate: Encourage Provider Collaboration to Ease Member Burden and Avoid Escalation
When appropriate, skilled teams can work with providers to reduce member responsibility. This can help turn a potentially burdensome bill into a manageable one – sparing members from prolonged stress and helping payers avoid costly surprise billing disputes.
“I was very committed to getting the claims resolved and knew the necessary steps to take,” shares Heather of a recent bill support experience.
This doesn’t just reduce financial strain — it builds confidence. Members feel heard, supported and informed. And while these pillars may be exemplified by certain programs in the market, they represent a broader shift in how payers can — and should — approach OON billing support.
Real-World Examples of Out-of-Network Billing Support
While the shift toward member-centric billing support is gaining traction across the industry, its impact is best understood through the experiences of real people. These stories – straight from the Zelis Health Bill Assist® team – illustrate how strategic support can transform the billing experience.
- A member faced a $1,228 bill from an OON emergency physician group due to being incorrectly listed as self-pay. With guidance and advocacy, the claim was reprocessed correctly, and the member’s financial responsibility was eliminated.
- In a more complex case, a member’s claim was denied due to a motor vehicle accident. After a thorough investigation and correction, the member saved over $7,000.
- Even smaller interventions matter: a routine vision claim misclassified as medical was corrected, saving the member $171.
These examples aren’t just about savings. They’re about restoring confidence. They reflect the power of a model that listens, educates and advocates. The principles leveraged — payer-driven investment, provider-conscious collaboration and member-centric support — are universally applicable.
How Payers Can Improve Out-of-Network Billing Support and Member Trust
Reimagining OON billing support isn’t just about solving individual member issues. It’s about reshaping the payer’s role in the healthcare experience. The most effective models are built on three foundational principles:
- Payer-driven: Strategic investment in member support services signals a shift from reactive problem-solving to proactive experience design. By embedding billing support into the broader member journey, payers can reduce friction, improve satisfaction and differentiate themselves in a crowded market.
- Provider-conscious: Collaboration with providers is essential — not only to streamline documentation and reduce administrative burden, but also to avoid costly and time-consuming surprise bills. When payers and providers work together to resolve billing discrepancies, everyone benefits.
- Member-centric: At the heart of this model is empathy. Members are looking for reassurance as much as they are answers. Personalized support, clear communication and timely intervention can turn a stressful billing moment into a trust-building opportunity.
These principles aren’t theoretical. When payers embrace this model, they don’t just improve billing — they elevate the entire member experience.
A New Standard for Out-of-Network Billing Support
As healthcare continues to evolve, so must the systems that support it. OON billing is more than just a transactional challenge. It’s a moment of truth for member experience.
Meeting modern expectations means going beyond reactive support to deliver proactive education, accurate resolution and meaningful engagement.
Zelis Health Bill Assist is setting a new benchmark for OON support. It was recently recognized by the industry with the MedTech Breakthrough Award. See how the team can help you build trust and offer better support to your members.
