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We’re often talking about the latest trends within the health insurance segment, so health plans can anticipate and prepare for success in today’s ever-changing environment. And a lot is changing; it seems almost daily. Of course, digital enhancements and virtual strategies are always the way forward. But there are other strategies that health plans should adopt now to improve member transparency, especially to respond to new legislation and standards coming out of Washington.

For example, the No Surprises Act outlines new guidelines intended to prevent individuals from facing surprise or uncertain costs regarding healthcare. Compliance within these new guidelines means leveraging some of these tips for improved engagement and member management. Transparency in pricing may be a requirement with these new rules. But it also translates to additional member retention advantages today’s health plan providers need for success, as well.

The HHS Announcement Protecting Consumers from Costly Surprises

Earlier this year, HHS announced some of the first guidelines in a series of regulations, as part of the No Surprises Act, protecting Americans from financial hardships as a result of surprise medical costs. Called the “Requirements Related to Surprise Billing; Part I,” this latest initiative aims to restrict what HHS calls “excessive out-of-pocket costs” for healthcare. These consumer surprise scenarios happen more often than you might think as a result of patients unknowingly seeking care from out-of-network healthcare providers. In other situations, individuals experience balance billing when healthcare invoices arrive, often presenting exorbitant costs that insurance didn’t cover. Balance billing is already prohibited in both Medicaid and Medicare platforms. But now, these provisions will extend to commercial health insurance plans and employer-sponsored group plans, as well.

What the Latest No Surprises Act Requires

As a health plan provider, there are new guidelines to consider as you look to explore member transparency and experience improvement. A few key measures outlined in the HHS statement include:

A Ban on High Out-of-Network Cost Sharing – Co-insurance, deductibles, and other cost-sharing stipulations can’t be higher than in-network provider pricing. And this applies to both non-emergency and emergency health services.

A Ban on Surprise Billing – Emergency services can be incredibly expensive, especially if a patient seeks care outside of the insured network. This provision says regardless of where a consumer finds treatment, billing must reflect in-network pricing unless prior authorization exists.

A Ban on Surprise Out-of-Network Charges – While similar to the ban on non-network cost-sharing, this ban speaks directly to both healthcare providers and insurers, requiring plan language definitions of pricing and notification of impending costs. Patient consent is required for any out-of-network treatments to ensure the patient doesn’t face surprise expenses after the fact.

A Ban on Out-of-Network Ancillary Care – When patients find in-network providers for care, they sometimes receive surprise bills from assistants or anesthesiologists who are out-of-network. This HHS provision addresses these surprises by prohibiting out-of-network charging in these ancillary scenarios.

How Health Plans Should Adapt

As a health plan, these latest guidelines and standards should be the priority. But other ongoing efforts can help reduce friction with members and increase price transparency. Member communication is paramount when it comes to informing patients of in-network and out-of-network parameters, for example. Sending reminders and securing permissions prior to healthcare treatments can help ensure members know what to expect prior to care.

Adapting also means looking for new ways to improve interoperability in sharing patient data between providers, health plans, and patients alike. For example, when an individual needs a surgical procedure, he or she will need to have access to all relevant data from the surgeon, primary care physicians, ancillary providers, labs, and surgical facilities. As a health plan, your platform can improve in a way that connects this critical data in an easy-to-navigate dashboard.

Why Upfront Pricing and Transparency Matters

Transparency in pricing matters for consumers, but it should also matter for health plans and healthcare providers. CNBC reported that nearly two-thirds of all bankruptcies filed in the U.S. involved lofty medical expenses. Other research suggests that one out of every six visits to an emergency room involves care from at least one out-of-network provider. Emergency room transport has staggering numbers as well, according to a study by the Government Accountability Office in 2019. The average cost of air transport rose from $36,400 to $40,000, with more than 70 percent of them representing out-of-network providers. It’s those surprise costs the No Surprises Act seeks to remedy. And when patients can’t pay their bills, it hurts their own financial health as well as health plans and providers seeking payment.

Some sources suggest that a majority of Americans have some level of distrust of insurance providers. This distrust leads to member churn and reduced engagement. Health plans should look for innovations in technology, like Enhanced Direct Enrollment, to bridge those gaps and rebuild loyalty and trust. Members will trust what they consider to be transparent, especially when it comes to pricing. You might not be sure what software initiatives your platform needs to make these improvements, but Softheon does. Connecting with the right partner can ensure your health plan offering engages, informs, and communicates seamlessly and effectively with every online interface.

Washington plans to roll out additional measures as part of the No Surprises Act, and health plans should be ready to shift toward compliance. No one believes members should face financial ruin due to a miscommunication of in versus out-of-network provision. Providing your valued members with the data they need to make the necessary health decisions they face will only solidify your company’s member relationship.

When you’re ready to improve your member experience by way of pricing transparency or member engagement strategy, let Softheon be your guide. You won’t likely have to make significant software overhauls at once if you’re able to carve out a more manageable transition plan to a better and more compliant consumer platform. As part of the journey, you’ll also want to explore member-centric connections that improve overall retention and growth too.