Out-of-network billing represents a smaller portion of claims than in-network ones for many payers. However, given its complexity, it can significantly strain resources and negatively impact member experience.
The shift to remote work has expanded employee locations in recent years, complicating network access beyond regional boundaries. Health plans must now address more out-of-network (OON) claims to ensure coverage for remote employees. Supporting these claims is essential to maintain satisfaction, as it reduces financial stress and ensures access to care, regardless of location.
From the payer perspective, navigating out-of-network claims is time-consuming. The landscape is fraught with regulatory considerations, and the potential for a negative member experience is high. The challenges mount, but payers are already operating with budget constraints. They need help.
How can partnering with an external vendor for member support help payers solve these pressing out-of-network claims challenges?
The out-of-network landscape
For health plan members, out-of-network claims can be a significant financial burden and a confusing experience to navigate. For providers, they can demand additional billing department resources and ultimately end in uncompensated care. Those experiences can impact the relationship payers have with their customers and providers.
In addition to managing these valuable relationships, payers must keep on top of a shifting regulatory landscape across all their markets.
Developing and maintaining the specialized knowledge required to maintain positive relationships with all stakeholders and regulatory compliance is a significant task for payers operating in a resource-constrained environment.
Scalable expertise
Addressing out-of-network claims challenges, which can vary across different markets, requires specialized skills. An external vendor can bring the necessary expertise and technology to manage out-of-network member support for payers. That strategic partnership can augment payers’ internal capabilities. With that outside help, payers can focus on their core operations and balance the demands of in-network and out-of-network member support.
Out-of-network member support vendors have access to significant amounts of data they can leverage on behalf of their payer partners. Advanced data analytics can open the door to improved member engagement and more savings opportunities.
“From the payer side, it allows them to focus on the other things that are important, to focus on their member relationships,” says Hilary Chapman, Voice of Client Director at Zelis.
One of the most pressing challenges of the out-of-network space is its dynamic nature. The challenges can vary from market to market, and they constantly evolve. A member support partner provides a solution that scales with these changes and a payer’s needs without straining their teams and budgets.
Just as the out-of-network space varies, so do the needs of individual payers. No one-size-fits-all solution is the answer.
“Each health plan is unique, with its own perspective and strategies,” says Michael Chang, Vice President of Negotiations and Claims Management at Zelis. “We aim to align our tools and skills with a plan’s specific strategy to best manage their claims.”
A scalable member support solution helps payers manage their existing business and strengthens their relationships with brokers who drive new business. Brokers can show new groups how the right member support tool brings value to their members.
Compliance support
In the out-of-network space, bill assistance can help manage claims by navigating the complexities of the No Surprises Act (NSA) and varying state regulations. As legislation evolves, payers must continually reassess their strategies to stay compliant and reduce administrative burdens.
“The legislation is still very fluid and subject to change,” says Carrie Gardner, Vice President of Product, Out-of-Network at Zelis.
A strategic partner with expertise in regulatory compliance can help guide payers through complex processes, including negotiation and resolution, minimizing risks and ensuring they stay compliant with evolving laws. “Payers can trust that we have the scale, experience, and capacity to manage the process effectively,” adds Gardner.
Working with such a partner provides payers the flexibility and resources to meet legal obligations efficiently, easing the administrative load.
Member satisfaction
Less than half of health plan members are satisfied with their health coverage, according to a 2023 survey. Good customer service is one of the most impactful actions payers can take to improve member satisfaction.
Bill assistance solutions play a key role in addressing member satisfaction, particularly around complex out-of-network billing. By partnering with a vendor focused on out-of-network claims, payers can enhance their offerings to groups and members, providing support that ensures bill accuracy, facilitates balance bill resolution, and negotiates on the member’s behalf.
“It’s vital to have a member-centric viewpoint,” says Chapman. This partnership not only improves the member experience but also allows health plans to offer expanded services that benefit clients and their HR departments, ultimately driving retention.
“Plans focus on members first, empowering them with education to deliver a great consumer experience,” Chapman adds. The expertise provided by an external partner helps alleviate stress for HR teams by providing resources and tailored support, boosting both member satisfaction and client loyalty.
Health plans can expand their service portfolio with the right external partner and deliver improved financial outcomes, compliance, and member experiences, ultimately leading to higher customer satisfaction and retention.
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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.
