Zelis Helps Address New NSA and TiC Regulations

Zelis, October 5, 2021

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), published October 2020, provides consumers better insight into the cost of services before obtaining care and receiving a bill.

We know what you’re thinking. The deadline for compliance is rapidly approaching.

We’ve got your back.

We also provide legislative expertise and guidance to help plans manage the complexity introduced by both the NSA and the TiC Rule.

And while these new requirements will add complexity to healthcare claim processing and administration, both pre- and post-service, the ruling's most significant impact lies in two key areas: transparency and member engagement and out-of-network (OON) claim processing and payment.

How Zelis Helps

Machine-Readable Files (MRFs)

Zelis Machine-Readable Files will address out-of-network (OON) MRF data requirements for Zelis-priced OON claims. We will also offer in-network (INN) MRF data with median INN rates for clients whose primary networks are owned or managed by Zelis.

ID Cards

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.

Provider Directories

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.  Moreover, we 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, provider, and geography.

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.

Post-Payment Settlement

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 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.

The Wrap Up

The No Surprises Act and Transparency in Coverage Rule will impact all healthcare organizations, from large health plans and systems to small medical offices and individual providers. As such, leaders across the healthcare industry must directly understand the details of the legislation prior to implementation or have a trusted advisor with legislative expertise who can guide them to appropriate solutions.

Zelis can help.

To further explore getting started with NSA compliance, reach out to your Zelis representative or contact us here.

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

It’s Time to Go Digital with Your Payments: Here’s Why

Zelis, August 31, 2021

Electronic claim payment trends all point to one dynamic: faster turnaround.

Simply put, businesses and consumers now expect near-immediate access to funds when they have been given notice of transfer. Luckily, that era of real-time payments is not too far off for health plans.

Today, multiple factors are converging that place the future of digital payments in a broader context (i.e. the introduction of new payment models and the ever-changing reimbursement landscape). Priming for success necessitates health plans ask the right questions to design near-term and long-term payment strategies.

That question? How does faster money movement impact how my organization does business?

 

Looking at the data

82% of consumers want to make their healthcare payments in one place, and 85% of consumers say they prefer an electronic payment method for their medical bills—yet most providers still send out paper bills.

In fact, only 20% of patients make online healthcare payments. And 86% of patients receive paper medical bills.

Moreover, the U.S. healthcare system racks up higher administrative costs than any other healthcare system. Private health plans alone spend $158 billion on administrative costs each year, with average administrative costs per payer hovering around 17.8%.

While many payers have implemented some form of electronic payment, many initial technology deployments were launched to meet compliance requirements as a response to market pressures. Few organizations considered long-term viability or coming advances when setting their plan in place.

Meaning: You’re simply not getting the most out of your current systems.

Getting started: The near-term

You may have taken the plunge into electronic payment by implementing automated clearing house (ACH) payments. But this is merely the foundation for maturing digital payment strategies.

Short-term strategies should focus on incremental steps that allow for the evolving world of faster payments.

The reality is that ACH typically only covers 80% of healthcare transactions. So you’re still relying on legacy processes (i.e. paper checks) for the remainder of payments.

Next steps: Future positioning

Health plans must develop strategies that consider where both the industry and digital payment market is headed over the next five years.

Some trends may include:

Growth of consumer-directed healthcare, tax savings accounts, and high deductible plans.

Shifting consumer behaviors and evolving digital expectations driven by the pandemic are requiring healthcare businesses to reprioritize. Payers and providers must consider the adoption of digital payments to meet the increasing consumer demand.

With an increase in patient financial responsibility, providers are looking to health plan partners to collect payments. Even more notably, most patients are looking for digital payment options.

In fact, 95% of patients indicate they are willing to pay a bill, while only 20% of organizations indicate they have the infrastructure to meet this experience.

Going forward, you should consider how to best navigate changing reimbursement models and work with providers and consumers.

Emerging payment technologies.

The use of peer-to-peer payments and digital wallets has grown in popularity, especially among younger generations. And while this isn’t directly applicable to the healthcare industry just yet, such payment systems are becoming the norm and with that come certain consumer expectations.

Venmo, one of the first applications to become mainstream, offers consumers a way to directly transfer money to another person. It takes a couple of days to get funds from Venmo to a consumer’s bank account, but other applications, like Zelle, are changing that dynamic.

The problem? The evolution of these technologies run in stark contrast to ACH processes, where a payment is posted, but a provider may only be able to access a percentage of the amount owed the first day.

That’s why it is vital to prepare for short-term and long-term needs. Payer executives can (and should) establish goals and strategies that align with industry and other digital payment movements.

The Wrap Up

It’s time to retire the 1980s-era healthcare billing and payments. And looking at healthcare’s transformation as an opportunity, rather than a forced change, is key.

The effort of conjoing healthcare with digital payments and data is central to treating patients like paying customers… and treating healthcare as a business — a mindset adjustment that organizations urgently need to make, as the ability to receive bills quickly and digitally, and pay them in the same manner, has become critical in today’s digitally-driven world.

If you’d like to see what Zelis is doing for the new wave of healthcare digitization, please reach out to your Zelis representative or contact us here.

Understanding the No Surprises Act

Zelis, July 28, 2021

The No Surprises Act, signed into law December 27, 2020, represents a significant change in the way out-of-network providers can bill and be reimbursed.

Starting January 1, 2022, the legislation prohibits providers from balance billing members during:

1. Out-of-network emergency items and services

2. Out-of-network nonemergency items and services provided in in-network facility

3. Out-of-network air ambulance healthcare items and services

But there are some exceptions based on provider notice and member consent.

For reimbursement, providers and health plans are provided a number of opportunities under the Act to settle on a payment amount. If reimbursement cannot be settled upon, either party can access a binding Independent Dispute Resolution (IDR) process. This final-offer arbitration process will use a government-approved entity to choose either offered rate as a final determination.

The goal? To eliminate medical bills received from out-of-network medical providers that the patient did not willingly choose, like in the case of a medical emergency.

How broad is the protection?

Protections apply to all commercially insured patients and to almost all out-of-network services.

The No Surprises Act will eliminate surprise bills for patients receiving:

  1. Emergency medical services from out-of-network providers
  2. Air ambulance services
  3. Non-emergency services at an in-network facility

 

How is payment determined?

Patients can expect to pay what they would pay for the same service if it were provided by a network provider.

For the health plan’s reimbursement to the provider, if there is an applicable state-required reimbursement process, the state law takes precedence. If there is no applicable state law, the Act outlines a reimbursement process to follow.

Under the Act’s process, a health plan reimburses the provider an initial payment. If the provider does not like the payment amount, the provider has 30 days to negotiate a different amount. If the negotiation fails, then either party may invoke arbitration. After both parties submit a proposed payment, the arbitrator must select one, with no ability to split the difference between the two proposals. The losing party must pay for the arbitration.

How will this affect health care costs?

The new bill could affect health care costs via three main channels, but CBO estimates that the No Surprises Act will result in less than a 1% reduction in premiums.

1. New administrative costs

Arbitration processes incurs administrative costs, via the typical fees associated with each arbitration case, as well as the staff time and resources needed to manage the process.

2. Settled payments

By making arbitration outcomes more predictable, providers and insurers will have shared expectations about how the arbitrator will ultimately rule and may recognize that reaching a negotiated agreement close to what the arbitrator will ultimately decide can allow them to avoid associated arbitration fees.

Agencies can also reduce the per-service administrative costs of arbitration when it does occur, although this could lead to prices higher than those that would have been paid prior to the No Surprises Act.

What does implementation look like?

Implementation questions generally fall into three buckets:

1. Breadth

How widespread are the protections against surprise billing? Will they expand the list of specialities barred from balance billing out-of-network patients at in-network facilities? Will exceptions be made for certain advanced diagnostic lab tests that are typically billed out-of-network?

2. In-network rate calculation

To delineate the specifics of the median in-network rate calculation for insurers, a second set of decisions is needed. On what geographic level are insurers required to make these calculations? How do organizations implement the rules for dealing with new carriers, newly-covered services, or services where an insurer has an insufficient number of provider group contracts?

3. Arbitration process mechanics

Regulators will need to specify how certification of arbitrators will work, as well as how the federal government will select an arbitrator if the parties fail to agree. How does one deal with other factors that might impact pricing, like the parties’ market shares? Can arbitrators make decisions separately for each service in dispute, or are they required to choose between the insurer and provider final offers for the entire batch of services?

The wrap up

The No Surprises Act addresses the root market failure that created the surprise billing problem (aka a patient’s lack of choice of provider for certain services). But it also presents new challenges, as providers are now required to treat any patient regardless of ability to pay. Hopefully, the law’s new arbitration process will fill that role.

For more information on NSA, visit our Info Hub.