Surprise! Payers’ Data Struggles with the No Surprises Act

In late December of 2020, bi-partisan legislation known as the No Surprises Act was passed by the U.S. government.

The main purpose of the bill is to eliminate surprise medical costs for out-of-network services. Out-of-network medical costs are usually incurred with cases that require emergency services or out-of-network services housed at in-network facilities. For the patient, the No Surprises Act will serve as a tool for price transparency and as protection from those unexpected, costly out-of-network medical bills. For Healthcare Payers, the requirement is to provide good faith estimates for all costs of care as well as creating an independent dispute resolution process for settling out-of-network billing with the Provider.

Another impact of the No Surprises Act, specific to Payers, is that health plans, upon a member's request, must supply them with Provider status updates within 1 business day. To accommodate this requirement Payers will need to maintain accurate Provider Directories in near real-time. The thinking here being that an up-to-date Provider Directory will help members avoid those out-of-network services and facilities.

Data Challenges of No Surprises Act

There are a few major challenges associated with the No Surprises Act from a data and data management perspective. These challenges include:

  • A looming deadline – As mentioned earlier, the No Surprises Act was passed in late December of 2020. The deadline to have all aspects of the No Surprises Act up and running is January 1st, 2022. That gives Payers only 1 year to plan, organize and implement their No Surprises Act updates.
  • Quick turnarounds on Provider status – Many Healthcare Payers rely on legacy systems to intake, update, and report out provider information, oftentimes this also includes several layers of manual intervention. Typically, if the Provider’s network status has changed or has been discovered as inaccurate the process to revise this requires a lengthy and manual review. Once the changes have been accepted, applying the changes to the Payer’s Provider Directory can then take several weeks. This is important to understand because to remain compliant with the 1 business day requirement all workflows associated with this process must be adjusted accordingly.
  • Lack of defined requirements – As Payer organizations scramble to meet the conditions of the No Surprises Act, their IT groups are struggling to understand and define the User Acceptance Testing (UAT) processes. Most are still figuring out the appropriate sample size they’ll need to validate before they feel the process is complete. Did I mention the deadline is January 1st, 2022?
Accelerated Data Solutions for the No Surprises Act

If Payer organizations aren’t up and running by the government issued deadline, they run the risk of not being compliant with the legislation which can lead to costly penalties or other monetary losses. But hope is not lost!

An important solution that can help Payers expediate this initiative and get compliant sooner rather than later is selecting the appropriate technology. Specifically, a reliable ingestion tool that can bring together the data from the various external sources as well as Provider Management Platforms. The selected ingestion tool should also be equipped with fast processing capabilities to quickly produce sets of files that match the businesses records showing the provider status changes and its classification.

Equally as important is the technology’s flexibility. By utilizing a NoSQL database you can essentially skip over the data architecture definition of relational models by ingesting the data first and then focusing on modernized models. This also allows for the structure of the data to be easily manipulated. In a traditional relational database, data definitions are rigid and changing data structures would be a difficult and time-intensive undertaking.

The combination of a reliable ingestion tool and flexibility of the data warehousing permit for an accelerated way to store and structure data without losing precious time. This is good news for Health Plan organizations that are currently struggling to meet the approaching deadline.

Act Quickly

At Data Ideology, we are working around the clock with our Payer clients to update their current systems and processes ahead of the No Surprises Act January due date. Our extensive experience in the Healthcare Payer vertical makes us an ideal partner for organizations seeking accelerated Provider Directory solutions. Give us a call soon because time is of the essence. Don’t let the No Surprises Act catch you by surprise too.

Written by Margaret Simmons


Senior Consultant at Data Ideology

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Surprise! Payers’ Data Struggles with the No Surprises Act

In late December of 2020, bi-partisan legislation known as the No Surprises Act was passed by the U.S. government. The main purpose of the bill is to eliminate surprise medical costs for out-of-network services.