Next Generation Technology Optimizes Out-of-Network Claim Savings

​ ​By Rob Jackson, EVP, Cost Management Solutions

Strategies to control the inflationary impact of out-of-network (OON) claim costs must continuously evolve in order to truly be effective. Provider charge patterns vary widely across services and across the country, particularly on claims from providers who intentionally opt to remain out-of-network.  Recent data shows that charges could range from 33x Medicare to 95x Medicare in extreme examples.  (See Chart)

Stale cost management models with a rigid hierarchy of stacked solutions often miss out on important savings opportunities. These solutions fail to deliver the most impactful reimbursement result available on a claim because they:

• Ignore claim cost variability
• Are often focused on automation rather than outcomes
• Greatly reduce flexibility for the payer 

Conservative approaches to out-of-network claims management can lead to overpayment on many claims and cause unnecessary impact to plan costs. Moreover, ineffective programs can lead to high member liability, creating dissatisfaction with the plan and ultimately with the payer.

Data shows that even in less than extreme examples, OON charges in total greatly surpass inflationary results and have increased almost 20% over the last 3 years through 2019, reaching an average of nearly 600% of Medicare pricing.

Because a claim is not “just a claim,” the cost containment (or reimbursement) solution set should be more than just a layering of discount choices. Instead, a more effective solution uses a dynamic approach that enables the use of applicable savings channels for optimal results. Ineffective egregious claim handling can be one of the most problematic issues for any payer, creating significant claim overpayments impacting either the plan or the insurer costs. The concept of real-time claim analysis yields deeper savings, greater capture rates and reduced risk for egregious claims overpayment. The most successful cost management programs include a combination of savings channels orchestrated by technology, experience and analytics.

Key Components Of Successful Cost Management Programs

• Member Financial Advocacy: Using a combination of proactive member and provider outreach, a member advocacy program works on behalf of the member to reduce the risk of unfair balance billing.
• Provider Relationship Management: Reducing provider abrasion is important to any sustainable savings program. This may include proactive provider outreach and post-payment claim settlement support.
• Protection from Surprise Balance Bills: Leveraging in-house or partnered legislative expertise helps payers and plans yield savings and reduce the risk of surprise bills while ensuring compliance with current regulatory mandates.
• Reduced risk of abusive OON claims: Disrupt the traditional single-pass savings channel that stops at the first discount found by excluding those low quality discounts on egregious claims and instead repricing them with market-based reimbursements.

A Next Generation Out-of-Network Savings Model

The Zelis model, called ClaimPass^®, seeks to mitigate risk factors faced by the plan: egregious claim impact, provider abrasion and member dissatisfaction.

ClaimPass technology uses market-based reimbursement benchmarks to guide payment recommendations on OON claims.  These recommendations are informed by provider and service-level payment experience along with years of experience managing OON claims costs.  Zelis’ experience in handling services of all types, particularly those prone to OON encounters like emergency care and anesthesia, allows payers to trust the outcomes on claims. Using the ClaimPass model improves overall savings results by 25-30 percentage points over traditional strategies.

• Cost management strategies must incorporate service models that finding savings while carefully considering impacts to all stakeholders ‒ members, plan sponsors, and providers ‒ to reduce the risk of member and provider abrasion.
• Cost-shifting strategies can negatively impact the member’s financial wellbeing and often reflect negatively on the claim payer.
• Incorporating Member Advocacy into the ClaimPass service model ensures support to improve the member experience and reduce the impact of balance billing on OON claims.
• Arbitrary payment cuts to the providers create customer service and claims appeal issues.
• Validating reimbursement rates are market driven and supporting provider inquiries around pricing determinations allows payers to maintain positive provider engagement.

Employing ClaimPass ensures that payers have a cost management solution designed to support all stakeholders, including a dedicated member financial advocacy team and a provider settlement team. These teams support and complement the ClaimPass solution to improve the stakeholder experience and the plan success. Balancing risks associated with claim costs, member experience and provider engagement can be achieved through Zelis’ coordinated, next-generation ClaimPass program.

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