95% of Healthcare Insurers Report Concern on Achieving Compliance with the No Surprises Act

Companies are working toward January 1, 2022 effective date

Bedminster, NJ – May 6, 2021 – H.R. 3630 or The No Surprises Act (NSA), which was signed into law on December 27, 2020, provides protection nationwide for patients from surprise medical bills and prohibits balance billing for certain out-of-network care.  Although this is good news for patients facing crippling and often unexpected medical bills, healthcare insurers and providers must hustle to adjust systems, processes, and technological capabilities to comply beginning January 1, 2022.

According to a recent survey by Zelis, the leading payments company in healthcare, nearly all (95%) healthcare insurers expressed concern about the ability of the healthcare system to achieve compliance with the NSA by the deadline.[1]  While some states – Colorado, New Mexico, Texas and Washington – have existing balance billing laws to protect patients from unexpected and excessive healthcare costs, the NSA brings more complexity to the pricing, negotiation and settlement, and arbitration processes at a national level.

In the survey of more than 100 executives representing 85 U.S. healthcare payers:

  • More than a majority are concerned about adhering to the timelines required (64%) and transparency requirements (61%)
  • More than one-third (41%) expressed concern about setting the appropriate reimbursement levels, managing the Independent Dispute Resolution process (41%) and provider directory requirements (39%)

“The No Surprises Act impacts all healthcare organizations, from large health plans and systems to small medical offices and individual providers,” said R. Andrew Eckert, Zelis CEO.  “Like Zelis, leaders across our industry are convening to dissect the details of the legislation because understanding the law and implementing it are equally important.  Insurers will need tools and to invest resources into operationalizing the requirements.”

From the patient-facing Advanced Explanation of Benefits through to adjudication, arbitration and settlement, alignment with the NSA requirements will require companies to adapt internal capabilities or outsource solutions, most likely a combination.  Companies may have to alter their infrastructure and processes to administer all aspects of the law.

“The multiple requirements mandated in these policies will be a very difficult lift for providers and payers.  The healthcare industry at large will have to move quickly to understand and implement the data, technology and process requirements necessary to comply,” said Matthew Albright, Zelis Chief Legislative Affairs Officer.

According to proprietary research, the ability to provide accurate advanced explanation of benefits to member-patients and the tight timelines of within 160 days post-service which providers and insurers must complete adjudication, remediation and arbitration will be the most challenging areas for the system to tackle, particularly for substantial claims.

For more unpacking of the NSA from legislative and clinical experts at Zelis, the leading healthcare payments company, visit the Zelis No Surprises Act Information Hub.


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About Zelis

As the leading payments company in healthcare, we price, pay and explain healthcare for payers, providers, and healthcare consumers. Zelis was founded on a belief there is a better way to determine the cost of a healthcare claim, manage payment-related data, and make the payment because more affordable and transparent care is good for all of us. We partner with more than 700 payers, including the top-5 national health plans, Blues plans, regional health plans, TPAs and self-insured employers, 1.5 million providers and millions of members, enabling the healthcare industry to pay for care, with care. Zelis brings adaptive technology, a deeply ingrained service culture, and an integrated pre-payment through payments platform to manage the complete payment process. For more information, visit us at www.zelis.com and follow us on LinkedIn.

[1] Survey of 116 healthcare payer executives representing 85 payer health plans, third-party administrators (TPAs) and health planned-owned TPAs, conducted by Zelis in January 2021