Finding a Balanced Solution for Out-of-Network Claims through ClaimPass

By Mike Chang, VP of Negotiations and Claims Management, Zelis

Healthcare costs continue to rise as trends in out-of-network billed charges continue to increase along with providers’ expectations of reimbursement.  Moreover, TPAs, health plans and employers are craving more innovative ways to contain plan cost while ensuring they deliver the best benefits possible.  Zelis offers a flexible and configurable technology to tailor a custom solution to fit any client’s specific needs, ranging from a full referenced based pricing solution to a solution that secures results and guarantees no member balance billing.

By taking a best-in-breed approach, we introduced ClaimPass, a balanced, multi-layered approach to out-of-network claims that identifies claim errors, waste and abuse, and financial egregiousness.  ClaimPass technology enables Zelis to drive the outcomes of your out-network claims using our net cost analysis that’s based on benchmarks, claim edits, clinical and coding expertise and historical data resulting in maximized savings.

ClaimPass’ primary objective is to ensure reimbursement at a reasonable amount by applying savings through one of our savings channels: Claim Negotiations, Zelis Choice Agreements, Supplemental Networks or the Established Reimbursement Schedule (ERS).  ClaimPass uses parameters set forth by ongoing analytics to safeguard application of the best savings channel.

Also included in our ClaimPass process, our technology identifies specific claims to take a deeper dive into the clinical and financial components within specialty areas such as Ambulatory Surgery Centers, High Cost Drugs, Team Surgeries, and Air Ambulance providers.  These provider types typically yield large savings opportunities associated with miscoded claims, egregious billing and/or services not medically necessary that may not be easily identifiable.

Our overall approach, focusing on identifying provider tendencies along with ClaimPass, ensures you reimburse providers an amount that truly reflects market-based rates and claim accuracy without shifting costs to the member.  We strive to maximize savings and to ensure the most appropriate reimbursement for care with minimal balance billing for members.

For more information on ClaimPass, please contact us.