Healthcare providers are dedicated to caring for their patients but must balance patient care with the administrative demands of medicine. Managing billing is complicated and becomes more challenging with out-of-network claims.
Provider billing departments pour significant resources into managing out-of-network claims, but delayed payment, uncompensated care, potential compliance pitfalls and tense relationships with patients are still common.
The out-of-network space is complex, with multiple stakeholders. Not only do providers face challenges, but so do patients and payers. How can the right services partner help solve the out-of-network problems that providers and other stakeholders face?
Recognizing the challenge
Out-of-network billing puts more financial responsibility on the shoulders of members. Providers need to be paid for their services, but billing departments often struggle to collect from patients. The cost of chasing those payments adds to administrative burden and costs.
"The time spent on disputes, dealing with health plans, or pursuing members only adds to costs," says Michael Chang, Vice President of Negotiations and Claims Management at Zelis.
While the cost of administrative burden adds up, providers contend with payment delays and uncompensated care. Research has shown that providers assume they will not be able to collect patient payments in full.
"They budget to only collect 50% of all member responsibility," notes Carrie Gardner, Vice President Product, Out-of-Network at Zelis.
That outcome puts a strain on providers' cash flow and financial stability.
Tackling billing challenges
With billing departments already resource-constrained, how can providers tackle these billing challenges? The answer lies in creating a more patient-centric healthcare system. Payers and providers can engage a strategic partner to provide members with the support they need to navigate out-of-network bills.
The right services partner can work with patients to ensure providers are getting more reimbursement for the out-of-network care they provide. An expert team can work directly with them to navigate their financial responsibility.
"We can improve a provider’s ability to identify more members who have a high propensity to pay their bills, but may have challenges to meet the total owed on that billing statement, which facilitates serious conversations that work for both parties," says Gardner.
Engaging these patients saves time for providers and directly improves cash flow by getting those payments in an efficient, streamlined manner.
Taking some of that burden off the provider's plate can be a powerful way to reduce uncompensated care, which results in more cash flow and financial stability.
Maintaining compliance
Out-of-network billing challenges are not only a drain on time and financial resources. They also increase the risk that providers will run into legal disputes and non-compliance penalties.
Under the No Surprises Act (NSA), providers cannot balance bill patients for out-of-network emergency services or non-emergency services rendered by out-of-network providers at in-network facilities. Incorrect billing practices under the NSA and Affordable Care Act, as well as varying state laws, can result in significant fines for providers.
"States are now stepping in and saying that for fully insured plans not governed by federal legislation, they will implement their own or similar laws," Gardner explains. "So, it's not just one rule—it's potentially 50 different sets of rules."
And that legislation is not static. It can change frequently, challenging providers to keep up. A member support partner that works with health plans has the expertise and scalability to manage through the complex regulatory landscape and help both providers and health plans maintain the necessary regulatory compliance.
Strengthening patient-provider relationships
The relationships providers build with their patients are vital. Those connections are built on trust, and bad out-of-network billing experiences risk damaging that trust. Patients who receive an unexpected out-of-network bill could feel unprepared for that financial strain. According to a recent survey by GOBankingRates, nearly half of Americans have less than $500 in savings – and almost 60% of Americans have less than $1,000 saved.
Transparency and upfront patient education can minimize the risk of patient dissatisfaction and lay the groundwork for strong relationships. Health plans can work with an out-of-network member support partner to provide that education and engage patients throughout the billing process.
If patients feel they have support and guidance throughout the billing process, they will be more satisfied with their provider experience. "Providers want high patient satisfaction to help establish long-lasting relationships," says Chang.
Building a Positive Brand
Providers have much at stake when building their presence in their communities. A positive public image is essential in building the trust that fuels patient retention and new patient relationships.
Quality of care is, of course, at the heart of a provider's reputation. But financial support and transparency play a big part, too.
"A track record of helping members mitigate large out-of-network bills only continues to grow and strengthen their trust," says Hilary Chapman, Voice of Client Director at Zelis. "It provides members with better customer service, a better experience and a better outcome overall."
Providers and health plans can work with an expert out-of-network member support partner, like Zelis, to help create a more patient-focused healthcare system. Putting the patient at the center of healthcare not only benefits them. It also eases the provider administrative burden, improves their financial stability and builds more trust with their communities.
__________________________________________________________________________
Zelis is modernizing the healthcare financial experience by providing a connected platform that bridges the gaps and aligns interests across payers, providers, and healthcare consumers. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts. Learn more about our latest solution, Zelis Health Bill Assist, here.
