At this point, the No Surprise Act (NSA) should be anything but shocking. This law has been a hot topic for payers and providers since its passage at the end of 2020 and the beginning of its implementation on January 1, 2022. There has, however, been little forward movement. For example, there is still confusion about specifics and many payers report making few to no changes to their current processes.
During a recent webcast with industry experts about the future of out-of-network strategies, participants were asked how much their strategy changed because of the NSA and Transparency in Coverage Rule. Almost 40 percent of respondents shared that no changes had been made, and none of the respondents indicated their organization had completed all the changes required by the NSA. Despite the challenges faced by payers and providers, the No Surprise Act is here to stay, so it is imperative to understand where the NSA stands just over half a year into its implementation, and what steps lie ahead for payers and strategies.
The IDR and Other Challenges
Two of the biggest challenges according to Matthew Albright, Chief Legislative Affairs Officer at Zelis, are the functionality of the federal IDR (Independent Dispute Resolution) portal, and the complexity of the IDR process. The IDR portal was originally predicted to handle about 17,000 claims in the first year. Instead, the web site has handled approximately 120 times that number according to a recent AHIP report. Albright explained that the overloaded system will need a revamp to handle the IDR demand, similar to what was needed for healthcare.gov.
In addition to portal problems, eight lawsuits have been filed in the past six months, seven of them regarding the methodology providers and payers should use to determine a fair reimbursement amount on NSA claims. Currently, the Final Rule is at the White House in the concluding stage with the Office of Management and Budget, and it is expected to drop any day now. Payers are trying to remain agile while planning strategies in the context of these frequent changes.
Other Factors Driving Out-of-Network Strategy
The NSA is certainly a significant factor, but it is hardly the only one driving out-of-network strategy. Payers need to look beyond the NSA to recognize some of the other factors, including those outside of healthcare, that impact pricing such as legislative government, economic factors, and healthcare industry trends.
From current economic issues like the workforce shortages and inflation to healthcare trends like the focus on mental health and benefit plan design, payers are considering each of these factors to understand individual needs and how they should influence pricing strategy development. As payers focus on the future of their strategies, they must consider multiple implications like networks, reimbursement, benefits, and member empowerment.
With full visibility into median network rates, Lisa LaMaster, VP of Business Solutions OON at Zelis said, “networks are under scrutiny now to bring value.” This means payers need to think about networks differently than they have in the past. The transparency created by the NSA also has resulted in more scrutiny being placed on reimbursements and pricing. In turn, this has led to a greater need for robust provider negotiation teams. These teams help payers keep their focus on the goal of shielding members from overcharges and negotiations, and delivering on the promise of greater transparency
As members become more empowered, they are seeking education from payers. While the NSA has eliminated hidden fees and allowed for price and plan comparison, LaMaster noted that healthcare is not the same as clothing shopping; luxury brands with costly price tags may denote quality and extravagance in clothing, but more expensive healthcare is not always better. Payers should try new strategies, like on-site events and webinars, to share information. “I don’t think it’s possible to overcommunicate,” expressed LaMaster. With so many societal-level changes, providers need to be open to considering what drives value and connects with members’ needs. This is especially true as attitudes to employee benefits are changing. Before the pandemic it used to be that any benefits were the goal, but in today’s world, employers are using benefits to as a competitive advantage to attract and retain talent.
Healthcare and health insurance have undergone significant changes because of the NSA and the current state of the world. Payers need to remain agile and adjust to changes that will benefit members and providers. Crucial next steps will include digitizing paper-heavy processes to streamline the sharing of information with members and understanding and taking advantage of the massive amounts of data that will become available through initiatives driven by the NSA.