Two-thirds of adults worry about paying unexpected medical bills. Even after paying copayments and premiums, members might face hefty out-of-pocket bills due to out-of-network charges. So what happens next? Out-of-network billing is a complex process and often beyond members’ knowledge or control.
“Most members have limited choice. It happens to them, or they have no other choice,” says Carrie Gardner, Vice President of Product, Out-of-Network, at Zelis. That lack of choice is one of the major out-of-network challenges for members.
Understanding out-of-network challenges
High-deductible health plans (HDHPs) have increased member engagement in the healthcare financial process upfront, but the introduction of the No Surprises Act (NSA)has added further complexity. The law was enacted to protect consumers from receiving unexpected bills for emergency care and non-emergency care from out-of-network providers at in-network facilities.
The NSA has prevented millions of surprise medical bills, but understanding their rights remains a challenge for consumers. “It’s a consumer protection, but consumers don’t know that. They don’t know what it means, and they don’t know when it applies,” says Gardner.
Common issues with out-of-network billing
The complexity continues. External apps may not always have accurate provider network information, causing confusion. Remote workforces also face challenges in ensuring network coverage for all employees.
Imagine someone needing care and choosing a provider they think is a good fit. In rural areas with limited networks, are members asking if providers accept their coverage or are in-network? Months later, EOBs and bills arrive. What do they mean? How much does the member owe? Are they protected under the NSA?
Answering these questions is not easy for the average health plan member. The result is often anxiety, on top of whatever health issues they are experiencing, and financial strain. Approximately half of adults in the U.S.cannot pay an unexpected medical billof $500 without going into debt, according to KFF.
But there are a few things that can alleviate members’ unease around out-of-network billing.
Three key strategies to solve out-of-network challenges
1. Educate members
With the rise of consumerism in healthcare, health plans play a significant role in addressing billing concerns for their members. Plans can empower consumers to make decisions that give them more control over their healthcare costs.
“Do they understand the basics of healthcare, such as the differences between plan types—like a PPO versus a high-deductible plan—and how their healthcare usage can guide them in choosing the most suitable option?” asks Michael Chang, Vice President of Negotiations and Claims Management at Zelis.
The first step is a clear, easily understandable picture of their plan options. Health plans can provide that.
Support teams can then continue to offer that knowledge and transparency. “We want members to understand not only that they went out of network but also the implications and the protections available to them,” Chang explains. Educated health plan members are more aware of how to use their benefits and their rights regarding out-of-network billing.
2. Improve billing accuracy, negotiations
Even informed members may find out-of-network billing complex. Their experience in an out-of-network situation impacts their relationship with their health plan. If they face a hefty bill without understanding why, their satisfaction may drop.
Health plans need an expert team that understands the ins and outs of billing practices to ensure a claim has been billed accurately and no unnecessary cost is passed to the member.
An expert support team can resolve billing inaccuracies, negotiate balance billing, and reduce financial strain for members. Strong member support allows members to initiate an expert review and potentially enter negotiations with providers. “Historically, most people haven’t realized that negotiating with a provider was even an option,” says Chang.
Expert member support teams can change that by proactively reaching out to members. “We’ll reach out and ask the member if they knew they went out-of-network and let them know we’re here to help negotiate,” Gardner explains. “We need to meet members where they are.”
3. Support the member journey
Members need support to manage their part in the out-of-network billing process, but for many payers, that remains an unfilled gap. “There is limited support to help members determine what they should pay or to provide the reassurance that someone is guiding them through the process,” says Gardner.
“Payers can partner strategically to enhance member support and close this gap. A qualified partner helps members tackle out-of-network challenges, providing the education needed to make informed decisions and move forward confidently.
Empowering members and enhancing satisfaction
Cost, access to care, and trust are what shape members’ experience with health plans. Effective support helps members understand out-of-pocket costs and reduce financial burden. It shows members how to leverage their plan to access care. The right support partner builds trust by guiding customers through out-of-network billing. Ultimately, a better out-of-network experience drives satisfaction and improves financial and health outcomes.
