Collaboration between payer and provider is beneficial for the patient



The intention of advanced EOB is positive because it is a critical step for patients to manage the cost of their care. Unfortunately, the workflow is faulty. (Photo: Shutterstock)

The No Surprises Law, a measure to end surprise medical bills for emergency and scheduled care, was passed to better inform patients about the cost of their health care.

Even with the application of requirements postponed to mid-2022, payers and providers must take a proactive approach to anticipate changes or not be in compliance. In preparation, payers and providers must meet as many legal requirements as soon as possible, so patients can have greater transparency about the cost of their care.

The role of the payer and the provider

The mandate places most of the responsibility on the payers. However, payers cannot meet this responsibility without engaging providers, as they are usually at the center of the conversation about the cost of care with patients. Providers should have all the information from the patient’s insurance company when discussing care options, making the collaboration between the payer and the provider a key piece of the puzzle.

Related: Consumers More Likely to Pay Hospital Bills If Costs Are Clear

The submission of Advanced Explanation of Benefits (EOB) requests and updating of supplier directory information are the primary requirements of the legislation. An advanced EOB estimates what patients will owe for services based on their current benefits, the amount of deductible remaining, and the reimbursement the provider will receive from the insurance company.

Bottlenecks and Benefits of Advanced EOB

The intention of advanced EOB is positive because it is a critical step for patients to manage the cost of their care. Unfortunately, the workflow is faulty. Advanced EOB creates additional administrative work for payers and providers without proper guidance, resulting in inconsistency in how changes are implemented.

With the law calling for advanced EOB requests to occur whenever a service is planned in advance – even if the patient does not need the EOB – payers and providers will have to process the request within within one working day. The law currently states that payers will be required to use the EOB through their claims handling system as a fictitious claim intended to generate an estimate of the payment. The resulting report is then sent to the patient. These steps are inherently difficult to manage and they create administrative bottlenecks, especially since the process is managed simultaneously with existing day-to-day reimbursement processes.

To create efficiencies, many in the industry believe that the payer should be responsible for sending the report to the provider and leveraging the provider as the patient access channel, helping both parties take the lead. better decision regarding the cost of patient care.

Look ahead

Patients must be at the forefront of their health care. With this law, patients will have better transparency on the cost of their care and accurate and up-to-date information on providers in the network. It is essential to have digital solutions and processes in place so that there is minimal disruption to operations and patient needs are met. The key is to ensure the collaboration of the payer and the provider for the benefit of the patient, and to ensure that the additional administrative processes do not result in higher overall costs to the system, which could be passed on to the patient. in the form of higher coverage and care costs. .

Christina perkins is vice president of product management and strategy at NantHealth.


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