Minimize the impact of new regulations.
The No Surprises Act (NSA), signed into law in December 2020, seeks to protect patients from surprise medical bills and prohibits balance billing for certain out-of-network care.
The Transparency in Coverage Rule (TiC) was published in October 2020. Its transparency provisions empower consumers with better insight into the cost of services before obtaining care and receiving a bill.
Zelis has created and enhanced our suite of integrated solutions to help you comply with these new regulations, improve your members’ experience, maximize savings and minimize provider abrasion. We also provide legislative expertise and guidance to help plans manage the complexity introduced by both the NSA and the TiC Rule.
These new requirements will add complexity to healthcare claim processing and administration, both pre- and post-service. There will be significant impact in two key areas: transparency and member engagement, and out-of-network (OON) claim processing and payment.
Machine-Readable Files (MRFs)
Zelis Machine-Readable Files will address out-of-network (OON) MRF data requirements for Zelis-priced OON claims. Zelis will offer in-network (INN) MRF data with median INN rates for clients whose primary networks are owned or managed by Zelis.
Zelis Member ID will enable enhanced ID card capabilities to print compliant ID cards with additional required information including member deductible, out-of-pocket maximum, and information on where to find in-network providers.
Advanced Explanations of Benefits (AEOBs)
Zelis Member Communications will publish compliant AEOBs, both print and digital, with the ability to handle increased volume.
Zelis will offer compliant directories for clients whose primary networks are owned or managed by Zelis.
Out-of-Network Claims Pricing with Median In-Network Rates
Zelis Market-Based Pricing offers payers a fully outsourced solution that meets No Surprises Act (NSA) compliance immediately upon implementation. Zelis can provide the Qualifying Payment Amount (QPA), provider payment amount, provider settlement, and support in an Independent Dispute Resolution (IDR.)
Market-Based Pricing calculates reasonable and acceptable reimbursements benchmarked by procedure, by provider, and by geography. Market-Based Pricing offers a far more comprehensive approach and delivers more defensible results than other solutions can offer.
Expert Pre-Payment Negotiation
Zelis Claims Negotiation succeeds through a combination of expertise, proactive provider outreach, and a demonstrable validity of market rates, driving a high rate of successfully retained savings – prior to payment. Because providers can no longer balance bill the member for NSA claims, their billing practices on these claims are likely to change. Zelis will offer expert guidance for negotiating with providers and incorporating market median data for NSA claims.
Zelis Claims Settlement manages the settlement process on your behalf to ensure compliance by defending, negotiating, and providing data needed for successful settlement, all within the timeframes required by the NSA.
Independent Dispute Resolution (IDR) Support
As part of the IDR process, Zelis Claim Resolution will leverage our negotiations and claim settlement expertise, provide data, analytics and reporting to support and defend clients in IDR, all within the time frames specified in the NSA.
Provider Behavior Insights
Some providers may use the threat of arbitration to persuade payers to settle for higher reimbursements. Zelis will help you understand of the impact of various pricing strategies and their likelihood of acceptance. Zelis will collect, aggregate, and analyze claims settlement and arbitration data to develop a predictive model that illustrates the overall effectiveness of pricing and arbitration results, and how those evolve over time.