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A Member Journey After the No Surprises Act: How Plans Meet Regulatory Mandates and Satisfy Members with HealthRules® Payer

Meet Janelle, a health plan member

Janelle has been struggling with knee pain ever since she sustained a basketball injury in college. Her finances are pretty tight, so when she finally decides to schedule a needed knee surgery, she is careful to make sure it is with a surgeon who is a participating provider in her health plan, YourHealth.

When it’s time for the surgery, Janelle checks in at Midtown Surgery Clinic, a participating facility and pays an expected co-pay. The surgery goes well and once the anesthesia wears off, she heads home to recover. Janelle does not anticipate any additional bills as she and her surgeon fulfilled all prerequisites of her coverage.

Prior to the No Surprises Act

Two months later, Janelle receives a $600 bill from Midtown Anesthesiology. After waiting on-hold with the clinic, then her health plan, Janelle finally speaks to customer service and learns that while her surgeon was in-network, the anesthesiologist was not. Now, she is responsible for a cost-sharing bill she can’t afford.

Behind the scenes, Janelle’s surgery results in multiple, separate claims to YourHealth. Midtown Surgery bills YourHealth for the surgery and Midtown Anesthesiology bills $600 for an anesthesiology service. During claim adjudication, YourHealth identifies the anesthesiologist as an out-of-network provider and processes the anesthesiology claim with out-of-network deductible and co-insurance responsibilities for Janelle, which results in her receiving the $600 bill.

This process takes over 60 days, leaving Janelle with a significant, unexpected bill that arrives months after a service she expected to be fully covered. The process leaves Janelle surprised, confused and angry with her health plan, the doctor, and the healthcare system in general.

She becomes disinclined to engage in the recommended follow-up services and may try to avoid everything but emergency services in the future.

After the No Surprises Act

Prior to the scheduled surgery, Janelle uses the price comparison tool through her member portal and easily confirms the cost of the surgery and what her cost sharing responsibilities will be.

Following the visit, the Midtown facility and physicians bill YourHealth for the surgery and a $600 anesthesiology service, minus the collected co-pay. The out-of-network anesthesiologist claim is processed applying in-network cost sharing, holding Janelle harmless from the higher out-of-network cost sharing amounts.

The facility and physicians who provided Janelle’s care send their service claims to her health plan. YourHealth, has prepared for No Surprises Act (NSA) compliance, leveraging the flexibility of HealthRules Payer to:

  • Configure out-of-network claims using NSA criteria
  • Auto-adjudicate the out-of-network claim appropriately using the Qualified Payment Amount for the service
  • Populate price comparison tools with provider and member-specific details using HealthRules Payer’s Trial Claim Feature, so Janelle was able to get personalized cost information well before surgery.

Later that year, YourHealth negotiates a slightly higher contracted fee schedule with Midtown Anesthesiology–expanding their network and improving provider and member satisfaction. They continue to monitor evolving NSA rulings, knowing that with the flexibility of HealthRules Payer they can prepare for future rulings like those anticipated for advanced explanations of benefits (AEOBs)–using the Trial Claim Feature and existing explanation of benefits processes to generate individualized claims detail for anticipated services.

Janelle receives no additional bill and engages in important physical therapy follow-up. By continuing to engage in preventive healthcare and treatment, Janelle optimizes her health outcomes and reduces lifetime health costs to herself and her health plan.

No Surprises Act, Regulatory Compliance, & HealthRules Payer

HealthRules Payer from HealthEdge, is a modern core administrative processing system with existing features that support plans in maintaining regulatory compliance. Designed for easy configuration, HealthRules Payer gives health plans the tools and support they need to succeed, even as transparency regulations evolve.

Learn more about how HealthRules Payer gives plans the tools to succeed as the No Surprises Act and industry regulation evolves.