After covering their copayments and premiums, health plan members may still be surprised by a hefty out-of-pocket bill, often due to out-of-network charges. What follows this unexpected expense? What happens next?
Two-thirds of adults are concerned about their ability to pay unexpected medical bills. Out-of-network billing is a complex process that members often have little knowledge or ability to control.
"Most members have limited choice. It happens to them, or they have no other choice," says Carrie Gardner, Vice President of Product, Out-of-Network, at Zelis. That lack of choice is one of the major out-of-network challenges for members.
High-deductible health plans (HDHPs) have increased member engagement in the financial process upfront, but the introduction of the No Surprises Act (NSA) has added further complexity. The law was enacted to protect consumers from receiving unexpected bills for emergency care and non-emergency care from out-of-network providers at in-network facilities.
The NSA has prevented millions of surprise medical bills, but consumers successfully understanding their rights still poses a challenge. "It's a consumer protection, but consumers don't know that. They don't know what it means, and they don't know when it applies," says Gardner.
The complexity doesn't end there. External applications designed to help members find providers may not always have accurate information about a provider's network participation, leading to further confusion. Additionally, remote workforces can create challenges in ensuring network coverage for all employees.
Imagine someone needing care and selecting a provider they believe is a good fit. Consider members in rural areas with limited networks to choose from. Are these members asking the right questions about whether providers accept their coverage or are part of their network before receiving services? Months later, explanations of benefits (EOBs) and bills start arriving. What do these documents mean? How much does the member owe? Are they protected under the No Surprises Act (NSA)?
Answering these questions is not easy for the average health plan member. The result is often anxiety, on top of whatever health issues they are experiencing, and financial strain. Approximately half of adults in the U.S. cannot pay an unexpected medical bill of $500 without going into debt, according to KFF.
Educating consumers
With the rise of consumerism in healthcare, health plans play a significant role in addressing billing concerns for their members. Plans can empower consumers to make decisions that give them more control over their healthcare costs.
"Do they understand the basics of healthcare, such as the differences between plan types—like a PPO versus a high-deductible plan—and how their healthcare usage can guide them in choosing the most suitable option?" asks Michael Chang, Vice President of Negotiations and Claims Management at Zelis.
The first step is a clear, easily understandable picture of their plan options. Health plans can provide that.
Support teams can then continue to offer that knowledge and transparency. "We want members to understand not only that they went out of network but also the implications and the protections available to them," Chang explains. Educated health plan members are more aware of how to use their benefits and their rights regarding out-of-network billing.
Improving billing accuracy, negotiations
Even when members are informed, navigating the complexities of out-of-network billing is still challenging. What happens after members find themselves in an out-of-network situation has a significant impact on the relationship they have with their health plan. If they are left with a hefty out-of-pocket bill and no clear understanding of why they owe that much, their plan satisfaction may be negatively affected.
Health plans need an expert team that understands the ins and outs of billing practices to ensure a claim has been billed accurately and no unnecessary cost is passed to the member.
An expert member support team has the skillset and provider relationships to resolve claim and billing inaccuracies, negotiate balance billing, and reduce potential financial strain for members.
Strong member support allows members to initiate an expert review and potentially enter negotiations with providers. "Historically, most people haven't realized that negotiating with a provider was even an option," says Chang.
Expert member support teams can change that by proactively reaching out to members. "We'll reach out and ask the member if they knew they went out-of-network and let them know we're here to help negotiate," Gardner explains. "We need to meet members where they are."
Supporting the member journey
Members need support to manage their part in the out-of-network billing process, but for many payers, that remains an unfilled gap. "There is limited support to help members determine what they should pay or to provide the reassurance that someone is guiding them through the process," says Gardner.
Payers can work with a strategic partner to augment their existing member support programs and close that gap. A qualified partner helps members tackle their out-of-network challenges. It can give consumers the education they need to make informed decisions about their care and move forward confidently.
When out-of-network bills arise, the dedicated experts at Zelis provide the necessary support to ensure claim accuracy and navigate provider negotiations.
Cost, access to care, and trust are three key factors that shape members’ experience with their health plans. An effective support solution can empower health plan members to understand their out-of-pocket costs better and reduce their financial burden. It can show members how to leverage their plan to access care. The right member support partner builds trust by guiding customers through the out-of-network billing process. Ultimately, a better out-of-network experience can drive member plan satisfaction and improve financial and health outcomes.
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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. To learn more about our latest solution, Zelis Health Bill Assist, click here.
