The No Surprises Act was implemented on January 1st of this year. Loren Adler, Assistant Director of the USC-Brookings Schaeffer Initiative for Health Policy, shared that the Act “is one of the biggest consumer protections to pass in recent decades.” The Act protects patients from unexpected charges when receiving care from out-of-network (OON) providers. While the Act delivers many positive outcomes for patients, payers and providers have been left to settle disputes over how to cover the rest of the bill.
Health plans and third-party administrators (TPAs) need to look further than their current approach to claims. Payers have traditionally used a fixed, singular strategy, which leads to over-payment and results in millions of dollars of additional costs for the business. Instead, innovative solutions from trusted healthcare savings solutions partners can find the balance between savings, provider acceptance, and reducing the time to settlement. Additionally, trusted partners can assist with negotiating and settling a dispute if one were to arise. If the dispute cannot be resolved and is transitioned to the Independent Dispute Resolution (IDR) process, partners can offer support and help navigate the proceedings. This final-offer arbitration process will use a government-approved entity to choose either the payer’s or provider’s offered rate as a final determination.
These cost management strategies incorporate the benefits from multiple channels on a claim-by-claim basis that maximize savings and meet provider acceptance, rather than stopping at the first discount found. Dynamic, optimized solutions are able to route claims to designated channels that decide the appropriate savings and maximize the OON claims savings. This leverages savings options and draws attention to savings instead of discounts. These solutions go further than the savings. These strategies consider the impact of all stakeholders from members, payers, and plans to providers.
The goal is to drive savings for payers and plans while reducing the risk of provider abrasion. This happens when the relationship between payers and providers becomes negatively influenced by certain situations, usually disputes about claims payments. Payers can avoid provider abrasion with fair market reimbursement offers, greater transparency, and timely payments.
An end-to-end strategic solution supports the needs of TPAs and health plans by increasing savings, while remaining aware of the balance between payers and providers. Strategies backed by savings solutions partners help support the relationships between payers and providers and find solutions to cost management goals.
