No Surprises Act and Transparency in Coverage Rule
Configurable solutions, legislative expertise and guidance to address the complex requirements introduced by new regulations.
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.
Through our acquisition of Sapphire Digital, Zelis offers a cost transparency tool that gives members and patients more control of their healthcare spending. SmartShopper makes it easy for members to select better, more affordable care and allows payers to meet the TiC and NSA price transparency requirements.
Machine-Readable Files (MRFs)
Zelis Machine-Readable Files address out-of-network (OON) MRF data requirements for Zelis-priced OON claims. Zelis provides in-network (INN) MRF data with median INN rates for clients whose primary networks are owned or managed by Zelis.
Zelis Member ID provides 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.
Out-of-Network Claims Pricing
Zelis’ market-based pricing is uniquely informed and calculated based on multiple claim-specific data points including proven commercial reimbursements, geographic specificity, procedure and provider details, and our propriety intelligence. Zelis has enhanced 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 market-based pricing helps payers achieve savings while reducing the risk of arbitration.
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 offers 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.
Zelis offers compliant directories for clients whose primary networks are owned or managed by Zelis.
Provider and Market 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.