Out-of-Network Services

A balanced approach meeting legislative requirements and driving optimal claim savings.

While other vendors using a traditional approach typically apply the first discount found which is not always the best discount — ClaimPass® digs deeper — using a multi-layered approach to utilize all applicable savings opportunities to find the best savings on out-of-network claims and to determine the best savings channels for those claims.

First, we work to get to the net cost of the claim by applying historical data, payment integrity technology, clinical and coding expertise, supportable benchmarks and scalable technology. This is important to ensure any savings and discounts are being applied on the lowest net claim cost rather than on an inflated price.

ClaimPass then determines the optimal discount by dynamically evaluating multiple savings options:

  1. Zelis Choice Agreements
  2. Negotiations
  3. Established Reimbursement Solution
  4. Supplemental Networks

Importantly, ClaimPass offers choice and flexibility and is configurable to meet the needs of all types of payers. It is truly smart enough to know how to optimize claims savings while ensuring adherence to the business rules of the client. And we know it’s working. Our clients have enjoyed an increase in overall savings – up to 350%! – on their out-of-network claims.


The No Surprises Act and Out-of-Network Claims Processing and Payments

New No Surprises Act (NSA) and Transparency in Coverage Rule (TiC) requirements will add complexity to healthcare claims processing and administration, both pre- and post-service. Meaning: there will be significant impact to the way out-of-network (OON) claims are processed and paid.

This is especially true in areas such as:

  • Calculating reimbursement amounts
  • Pre-payment negotiation
  • Post-payment claim settlement
  • Independent Dispute Resolution (IDR)
  • Provider and market insights

How Zelis can help

In addition to enhancing our solutions to address new requirements, Zelis will provide legislative expertise and guidance to help clients manage the complexity introduced by the new regulations.

The specifics

Calculating reimbursement amounts

Zelis is enhancing our market-based pricing with the ability to price according to median INN rates, accounting for the various factors that NSA prescribes such as acuity of patient and setting of care. Our defensible pricing helps payers achieve savings while reducing the risk of arbitration.

Pre-payment negotiation

Zelis routes all OON claims to savings channels based on NSA status and client parameters. Our defensible pricing is informed by multiple claim-specific data points including proven commercial and proprietary benchmarks, CMS data, provider acceptance history and facility costs by geographic area.

We are also enhancing our market-based pricing with the ability to price according to median INN rates, accounting for the various factors NSA prescribes (i.e. acuity of patient and setting of care). This helps payers achieve savings while reducing the risk of arbitration.

Post-payment claim settlement

Zelis Claims Settlement ensures settlement processes compliance by defending, negotiating, and providing data needed for successful settlement – all within the timeframes required by the NSA.

Independent Dispute Resolution

Under NSA guidelines, after 30 days of open negotiations either party (provider or payer) can initiate an Independent Dispute Resolution (IDR) with a third-party arbiter. As part of the IDR process, Zelis® Claims Resolution will leverage our negotiations and claim settlement expertise and provide data, analytics, and reporting to support and defend clients, all within the time frames specified in the NSA.

Provider and market insights

Zelis currently leverages our experience in out-of-network reimbursement and acceptance to inform pricing strategies and guidance for our clients.

Zelis will build on this experience and continue to collect, aggregate, and analyze claims settlement and arbitration data to develop insights about the overall effectiveness of pricing and arbitration results. These insights will then inform and guide OON pricing and settlement to reflect provider trends, allowing us to guide clients through a range of acceptable and defensible pricing scenarios. 

Learn More

To further explore NSA compliance and learn more about the new and exciting developments in our solution portfolio, reach out to your Zelis representative or contact us here.

For access to additional information, visit Zelis’ No Surprises Act Information Hub.