by Future Healthcare Today
In a previous episode of the Future Healthcare Today Podcast, the editorial team heard from three healthcare network solutions experts at Zelis about how payers can create and maintain a robust collection of providers and the benefits that this brings. However, the relationship is a two-way street, as there are many tangible benefits to joining a provider network that accrue to the provider as well. One of the most important benefits according to Tammie Skiles, Senior Vice President for Network Solutions at Zelis, is the predictability that comes from being part of a network. “Contracts are negotiated so everyone understands the agreement for services, fees, and schedule rates,” she told Future Healthcare Today. Additionally, there is an expectation that being in-network creates an easier path for patients to find a provider that will meet their needs. “As a provider, you really are looking for a partner who can steer members to your office, or chair as we say in dental,” Kim Sharbatz, Senior Director for Strategic Network Partnerships said. Ideally, an effective provider network ensures providers have few, if any, gaps in their schedule. Finally, as Robin Marino, Director for the Zelis Dental Network said, providers can also get further benefits through access to major carriers and TPAs. “It’s a big reason providers approach [companies like Zelis], you sign one contract and gain an opportunity to reach many members and can save time with compliance, network needs, and credentialing.” As providers navigate the next generation of healthcare needs and trends changing the industry, being a part of an established provider network affords the ability to thrive.
The healthcare network, made up of providers and managed by payers, is one of the most important aspects of the entire industry. It forms the foundation upon which patients base their expectations, the primary component which payers use to attract members, and that providers use to ensure visibility among patient populations looking for services. However, recent events have fundamentally altered the way all three use networks. To better understand the many changes that the healthcare network is experiencing and what these changes mean for building a robust payer network, Future Healthcare Today spoke with three network solutions experts from Zelis. “Member needs are changing,” Robin Marino, Director for the Zelis Dental Network said. Marino mentioned that trends like “dispersed workforces, work from home, new technology, all these combined with an evolving set of expectations from patients mean that payer networks need to change to keep up and remain competitive.” “[Building a competitive network] requires an understanding of patient needs, provider demographics, and geographic areas,” Tammie Skiles, Senior Vice President for Network Solutions, explained. “[Together these, among other variables] are how we define competitiveness of a network, and payer networks need to be competitive to be successful.” Frequently, however, health plans lack the resources to best track changes that impact their networks’ competitiveness. “If a health plan does have a network, it often isn’t their primary focus,” Kim Sharbatz, Senior Director for Strategic Network Partnerships, said. “They are more focused on growing their product ...making it tough for network areas to battle for resources.” This can be a problem for payers when their network is not keeping pace with the evolution of the healthcare industry. With payer networks at a crossroads and no sign of the pace of change slowing, Future Healthcare Today shares how to build a robust network and how to ensure its success for years to come.
Third-Party Administrators (TPAs) and health plans have many things in common, but one that stands out is the challenge both are facing in today’s healthcare industry. With digital transformation, ongoing demographic shifts, and a variety of other long and short-term trends, TPAs and health plans are facing significant headwinds when it comes to creating a modern healthcare network. Despite these challenges, there are many ways for TPAs and health plans to create competitive, cost-effective, and compliant networks. “Meeting member needs, and by extension reducing member abrasion, is one of the industry’s largest challenges,” said Maisie Weir, Director of Business Solutions. Weir noted that Zelis has found that by empowering health plans and TPAs to build, access, and manage networks it is possible to reduce pressure around resource constraints, and ultimately create high-performing network solutions. Erick Russel, Director of Network Operations at Zelis added that among the specific issues facing TPAs, finding ways to deliver value and creating access to strong networks is key to thriving in the modern healthcare network ecosystem. Russel added that “TPAs also need to be aware of how provider pricing variability has had a major impact on driving up traditional healthcare costs.” Payers have been searching for new strategies to help stabilize claim costs, Russell added. Indeed, his team at Zelis has seen an increase in the need for network replacement solutions, which he noted often included some form of reference-based pricing. But apart from the more industry-specific trends driving change, Kim Sharbatz, Senior Director of Strategic Network Partnerships, pointed to an overarching trend that is having an outsized impact on the industry. “We’ve said it time and time again, but in today’s world everything is virtual,” Sharbatz told FHT. “That means our workforces must become virtual as well.” This evolution has created challenges for health plans and TPAs because memberships have become widely dispersed which can make it difficult to build and manage network solutions to fulfill their access for their members. Sharbatz argued that creating a modern healthcare network requires a health plan or TPA to dedicate a large number of its resources to really understand networks and the market, or alternatively “they can work with a partner who already does all that and more.”
Accessibility and adequacy are two of the most important elements for healthcare plans today, and digital transformation has made both easier to track and provide. At their core, accessibility and adequacy revolve around the expectation that a health plan member can find not only the right healthcare provider for their needs but that they can do so easily. Being able to easily find the right healthcare provider has become a challenge for many people, due in no small part to the COVID-19 pandemic. Not only did populations shift, with many people leaving larger, more centralized locations in favor of more rural areas, but also because medical practitioners left the field. Despite the disruptions and changes resulting from COVID-19, patient expectations for their healthcare plans did not change, and many health plans found themselves scrambling to ensure adequate and accessible healthcare solutions were available in more places than ever before. How did plans adapt? Has the importance of both accessibility and adequacy remained? What should health plans do to better assess their networks for both? In the latest edition of the Future Healthcare Today podcast, Jillian Carlile, Senior Product Analyst for Network Solutions, and Paul Nance, Senior Product Analyst for Network Analytics, both from Zelis, share their thoughts on the enduring importance of both and what companies like Zelis can do to help plans meet and exceed expectations:
In the healthcare industry, a network is only as strong as its providers. As the frontline of care, providers must be ready, able, and willing to help patients as effectively as possible, and while there is no doubt that most, if not all providers, seek to be the best they can be there are times when one provider is better suited to respond over another. But what should networks do when choosing healthcare providers? For a healthcare network, understanding the strengths of each provider, coupled with an understanding of what the member needs, is the most important aspect of their job. But what matters when reviewing a provider? What considerations must be taken into account? Where can providers' metrics be seen and compared? To answer these questions and many more, Future Healthcare Today spoke with Paul Nance Product Manager at Zelis, whose career has been dedicated to helping providers be as efficient and competitive as possible. According to Paul, often times the most important qualities to look for when choosing healthcare providers may not be the ones you expect.
In a previous conversation, Madison Goldfischer, Vice President and Head of Product for Member Empowerment at Zelis, joined Future Healthcare Today, to discuss the recently released member empowerment research report. In that conversation, Madison noted that while there were many areas that payers and providers can work to provide their members with more clarity, guidance, and control, one area that was worth investigating was the member journey. With lingering concerns about the COVID-19 pandemic, along with the lifestyle changes that accompanied it, many individuals are interacting with their providers like never before. As payers and providers look towards improving the experience, Madison encouraged both to look at what their journey looks like for a member, and to focus on ways the journey can be streamlined and made more efficient. From providing clearer indications and expectations about the total cost associated with care, to making the process of connecting with healthcare providers easier, there are many solutions that can make the member's journey much easier and more painless for the member. “The member experience has changed significantly over the past 10 years… the experience has really evolved from just engaging with your health plan for the purposes of talking about a claim to a lot more ongoing engagement opportunities… the boundary is going to be pushed on how both care delivery providers and care plans or health plans themselves are actually delivering solutions.”
The healthcare provider market has been in flux over the past few years with the challenges of the pandemic impacting healthcare operations among other trends. To help providers better understand and manage the challenges of this uncertain environment, there are important trends to be aware of, like growth in providers contracting with managed care plans across the market segments. Additional findings from the recently released State of the Provider Network Market Report 2022 suggest there is a positive growth in new hospitals, with micro-hospitals in satellite locations being of particular interest. These have primarily opened in more rural areas and demonstrate a larger shift towards more accessibility for traditionally less serviced communities. Conversely, there is an increase in providers, but out of approximately 10,000 new providers, only two percent were in rural locations. These were the key themes discussed in the recent Future Healthcare Today podcast with Jillian Carlile, Senior Product Analyst at Zelis. Carlile provided insight into the current state of the healthcare provider market and the ongoing changing impacting it.
On January 1, 2022, the No Surprises Act took effect to protect patients from surprise medical expenses, but it has created tension between payers and providers. For example, on February 23, 2022, the U.S. District Court for the Eastern District of Texas struck down the part of the interagency interim final rule implementing the “independent dispute resolution” (IDR) procedures. When payers and out-of-network providers cannot agree on reimbursement, either party can choose to initiate an IDR. While the majority of the rule remains in effect, the changes from this case will impact health plans and the insurers that sponsor them. These were the key themes of a recent Future Healthcare Today podcast interview with Matthew Albright, Chief Legislative Affairs Officer at Zelis, and Cate Brantley, Legislative Analyst at Zelis, who provided a deep-dive perspective on the IDR process and its impact on health payers.
As 2021 draws to a close, transparency is one of the biggest conversations for health payers. In 2022, some requirements of the No Surprises Act and Transparency in Coverage Rule come into effect. As payers prepare to meet regulatory deadlines – both near term and those further out – it’s understandable that they might have questions they need answered. Both of these regulations are broad and far-reaching, and will have an impact on overall healthcare costs, as well as the contracted rates for payers. In addition, while many payers have already invested a significant amount of money for meeting these mandates, there’s much more than can be done today. These were the key themes of this Future Healthcare Today podcast, titled, “Transparency in Coverage: Helping Health Payers Understand the Final Rule,” with Dennis Charland, SVP of Sales at Sapphire Digital, which was recently acquired by Zelis. Charland has previous sales experience Blue Cross Blue Shield of Massachusetts, and provided a closer look at what Transparency in Coverage means for payers, and explored solutions that can help ensure compliance for both upcoming mandates.
The No Surprises Act was designed to protect healthcare consumers against surprise billing. For payers, it has made processes more complex, especially relating to ensuring that reasonable and acceptable reimbursements are established and benchmarked by procedure, by provider, and by geography. On September 30, 2021, the Department of Health and Human Services, the Department of Labor, and the Department of the Treasury along with the Office of Personnel Management released an interim final rule, which further explains requirements related to the Independent Dispute Resolution (IDR) process and Qualified Payment Amounts. Greg Tackett, Senior Vice President of National Accounts and Strategy at Zelis, joined our Future Healthcare Today podcast to further explore these new rules and how median in network solutions can help ensure reasonable and acceptable reimbursements. “When payers who are not used to going through arbitration today, or if they do go to arbitration, it's on a very small amount of claims, they're going to need help and support to put the best argument forward on why what they have paid the provider is fair and reasonable, because providers will probably push back on what they're paid,” said Tackett.