Payer and provider collaboration means benefitting the patient

The No Surprises Act, a measure to end surprise medical bills for emergency and scheduled care, was passed to better inform patients about the cost of their health care.

Even with requirement enforcement deferred to mid-2022, payers and providers must take a proactive approach to get ahead of the changes or be out of compliance. In preparation, payers and providers should meet as many of the Act’s requirements as soon as possible, so patients can have better transparency into the cost of their care.

The payer and provider role

The mandate puts most of the responsibility on payers. However, payers can’t fulfill that responsibility without engaging providers, as they are typically at the center of the cost of care conversation with patients. Providers need to have all of the information from the patient’s insurance company when discussing care options, making payer and provider collaboration a key piece of the puzzle.

Related: Consumers more likely to pay hospital bills if costs are clear

Submitting requests for an advanced explanation of benefits (EOB) and keeping provider directory information current, are top requirements within the legislation. An advanced EOB estimates what patients will owe for services given their current benefits, what amount of the deductible is remaining, and what reimbursement the provider will receive from the insurance company.

The bottlenecks and benefits of advanced EOB

The intention of advanced EOB is positive as it is a critical step for patients to manage the cost of their care. Unfortunately, the workflow is flawed. Advanced EOB creates extra administrative work for payers and providers without appropriate guidance, which causes inconsistency in how changes are implemented.

With the Act calling for Advanced EOB requests to occur any time a service is scheduled ahead of time – even if the patient does not need the EOB – payers and providers will need to handle the request within as little as one business day. The Act currently states that payers will need to take the EOB through their claims processing system as a mock claim that’s meant to drive an estimate of payment. The resulting report is then sent to the patient. These steps are inherently difficult to manage, plus they create administrative bottlenecks, especially as the process is managed simultaneously with the existing day-to-day reimbursement processes.

To create efficiencies, many industry players believe that the payer should be responsible for sending the report to the provider and leveraging the provider as the channel to the patient – helping both parties make the best decision about the cost of the patient’s care.

Looking ahead

Patients need to be at the forefront of their health care. With this Act, patients will have better transparency into the cost of their care and accurate, up-to-date information about in-network providers. It is vital to have solutions and digital processes in place so there is minimal disruption to operations and the patient’s needs are met. The key is to ensure payer and provider collaboration for the benefit of the patient, and to ensure the additional administrative processes don’t result in higher overall costs to the system, which could get passed on to the patient as higher costs of coverage and care.

Christina Perkins is vice president of product management & strategy at NantHealth.

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• Not just the bills: Health care’s administrative ‘sludge’ eating up employees’ time