Health Insurance Industry Issues and Legislation

The Departments of Health and Human Services, Labor, and Treasury along with the Office of Personnel Management have released their latest interim final rule (IFR) for implementation of the No Surprises Act. Included in the release are the steps in the dispute resolution process. Based on the release, it could take as many as 143 days from the time a claim is received until final payment to the provider. The IFR also includes the administrative fee and allowable independent dispute resolution entity fee ranges and makes the non-prevailing party responsible for the IDRE's fee. However, HHC has a way to avoid the time, effort and costs of going through the IDR process. Let us explain how!

The NSA expands on the provisions in the Affordable Care Act by making external reviews available for any (versus only certain) adverse determination that involves consideration of whether a plan or insurer complied with NSA provisions. For example; a patient can ask for a review if the plan determined a pre-stabilization emergency treatment in an out-of-network (oon) emergency room did not qualify as "emergency services". Or, a patient in a non-emergent inpatient setting can challenge whether they received appropriate notice and gave informed consent to waive their protections under the NSA regarding services performed by an oon provider.

Each year HHC asks its clients to tell us how we are doing for them. They let us know what we are doing well and what we can do better. They rate us in terms of the value we deliver and the advantage we give them in today's highly competitive marketplace. They also grade our overall performance, responsiveness and professionalism, and share some of their unmet needs as well as issues they'll have to address in the coming year.

Member engagement and communications are two keys to the ongoing success of any Reference-Based Pricing (RBP) plan. Plan members want a place they can easily access for coverage and information, keep track of where they stand in terms of fulfilling their deductible, see what their copays are, and identify providers who accept RBP for payment as payment in full. They also want someplace to go to tell them what to do if they get balance billed by a provider. HHC Group's Health Plan GPS (HPGPS) user-friendly mobile app and website are the ideal vehicles to engage with members, give them the information they need when they need it and reduce both plan and member healthcare costs.