The No Surprises Act Expands Provider Burden: Tech Can Help Ease The Pain
The recently enacted No Surprises Act has left healthcare providers scratching their heads and worried about their bottom lines and patient lives. Inconsistent interpretations by regulatory bodies nationwide have contributed to this confusion. Many of the operational mechanisms and strategic implications are surrounded by uncertainty and reliant on data and an interoperability infrastructure that simply does not exist today.
This article is not an explanation of the No Surprises Act (NSA), rather we aim to discuss three health system challenges worsened by the NSA and propose tangible solutions to help ease the burden of front-line providers.
Challenge 1
Providers are held responsible for every clinical interaction they have with providers who share in the same patient journeys. Full knowledge of one’s provider network is compulsory to avoiding fines, surviving inspections, and meeting regulatory requirements set forth by the NSA.
Beyond the administrative burden this presents, the health systems most affected by the NSA have never had full visibility into their patient journeys. Nearly half of all health system referrals end up outside of the system, outside of the electronic medical record (EMR), outside the grasp of their providers. The NSA is attempting to police a feedback loop that, to date, has not existed in US healthcare.
Solution 1
Health systems have a choice, they can lapse into passivity to avoid regulatory culpability and ultimately hurt their patients or they can utilize technology and novel data to reduce the uncertainty of every patient journey, intelligently direct every referral, and understand their provider possibilities at every transition.
Providers require nationwide visibility into care journeys, with in-system, in-network provider recommendations for every referral and procedure performed. Such a solution reduces the risk, uncertainty and fines articulated in the NSA verbiage. A readily available list of provider options for every care transition, referral and inpatient encounter makes the overwhelming requirements of the NSA much more tenable.
Only Monocle Insights offers a solution to providers. We curate 200M patient journeys annually, across hundreds of payors and include robust data on every provider in the US. Monocle Insights utilizes social network science and machine learning to deliver in-network provider alternatives to out-of-network referrals, ultimately giving providers the information they need to fully understand their network and put powerful knowledge into the hands of their patients - exactly what the NSA intends to do.
Challenge 2
Health plan provider directories are notoriously riddled with errors. Providers must rely on the provider directory of the health system or contact the plan directly to obtain information on alternative in-payor-network providers. This process does not guarantee accurate or timely information and is highly burdensome to providers and their entire staff.
In an open letter to legislators and regulators, the American Hospital Association (AHA) stated that the NSA should not hold providers responsible if they rely unknowingly on erroneous directory information. However, in the current state, erroneous information is all that they have, and that leads to pain that providers simply cannot afford if they are to keep treating patients who desperately need help.
Solution 2
Build and monitor a centralized provider payor/provider affiliation directory. We understand that provider, plan, and patient combinations can often feel like a revolving door, however, health systems need a single source of truth from which to make decisions and monitor why those decisions were made in order to comply with the NSA.
The easiest route for health systems is to aggregate payor/provider affiliations via each payor or provider, or source those data from intelligent product suites such as those built at Monocle Insights. While a directory is great, there also needs to be a process around this affiliation management, including quality checks on ever-changing payor statuses; something that is beyond the reach of most healthcare providers but within the grasp of those using Monocle Insights’ product suite.
Challenge 3
The No Surprises Act changes the market economics of US healthcare in favor of payors, leaving providers and patients vulnerable. Per the NSA, surprise out-of-network bills are required to be within a reasonable amount of the in-network charge (qualifying payment amount), lest providers pay a $10k fine for each offense. Providers must deliver a 3 day notice or a patient consent waiver for pricing estimates on post-stabilization services that may follow an encounter.
Such barriers to access are confounded by the fact that out-of-network care can be denied by the health plan, an action that is only appealed by patients <1% of the time. These factors put health systems and providers at a disadvantage to payors, who have already taken steps to manipulate rates, foreshadowing substantial provider pay cuts and intentionally reducing access to improve profitability.
The AHA stated that the NSA’s skewed process will ultimately discourage meaningful contracting negotiations, reducing provider networks, and encouraging unsustainable compensation for teaching hospitals, physician practices and other providers that significantly benefit patients and communities. This problem is particularly acute in regions where there is a monopolistic payor determining private healthcare pricing.
Solution 3
Health systems need to adopt data and tools to proactively improve their stature within the healthcare marketplace.
A health system’s grasp on every care transition, every encounter, and every provider attribute matters now more than ever. Providers and health systems, by nature of being the caregiver, still control these interactions, which form the building blocks of the healthcare marketplace in a region.
EMRs and adjudicated claims data available to health systems now tell only a portion of this picture, however, true marketplace strategy requires substantial data about care that occurs both inside and outside a health system.
A properly curated, region-wide, encounter-level data source can give providers a full view of their marketplace, helping them understand where issues of access, leakage, care gaps and pricing consequences may occur. As care evolves, health systems have the micro-economic insight available to identify, measure and fix issues before they become problematic.
Monocle Insights built a solution for exactly this purpose. The Care Milieu is a platform for understanding health system networks of care via the most comprehensive relational dataset in the history of US healthcare, giving administrators and providers deep, rich, cross-system insights into complete care journeys and patterns of care that reshapes patient lives and empowers providers across the entire health continuum.
If you enjoyed this blog, have questions/comments, or would like to learn more about Monocle Insights, please email info@monocleinsights.com or visit our contact page to schedule a demo!
