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Third-party administrators (TPAs), often tasked with the responsibility of meeting the requirements of the No Surprises Act (NSA) and Transparency in Coverage (TiC) rules, understand the gravity of non-compliance for self-insured health plans. And though TPAs play a key role in helping plans stay compliant, they may benefit from receiving direct support from a partner.
A partner with deeper access to the most comprehensive cost and quality data, as well as the ability to expertly navigate and execute all aspects of claim services, can help TPAs with numerous elements of ensuring compliance:
- Enhancing transparency
- Engaging members
- Managing out-of-network claim processes and payments
- Minimizing independent dispute resolutions (IDR)
To meet the legislative requirements of protecting patients from surprise medical bills and providing easily accessible information on the true costs of care, Vālenz® Health is the answer. Explore three approaches for helping TPAs ensure plan compliance with the NSA and TiC regulations:
Member-Facing Tools for Better Transparency
Acquired by Valenz Health in 2024, Healthcare Bluebook™ features a comprehensive compliance solution that helps TPAs address the critical mandates of the TiC regulations. The goal is to engage members early, giving them access to cost and quality information as they search for procedures and providers – before they have received care.
In other words, Healthcare Bluebook does the heavy lifting so TPAs and members don’t have to. With an extensive claims data set at its fingertips, Healthcare Bluebook integrates the data, distills it down, and makes it instantly understandable – using a simple green-yellow-red color-coded system for both quality of care and cost.
Healthcare Bluebook leans heavily on its historical claims data to guide members to the right place for the right care at a “Fair Price™.” This fulfills the legal requirement to share specific pricing while also protecting the member experience by paving a clear path to finding the right care at the right cost.
Although the TiC rules don’t address quality, Healthcare Bluebook does, because it’s often a significant factor in costs. Leveraging its data, Healthcare Bluebook strategically layers in that quality component to recommend the right provider for the right care. That means a decreased likelihood of unplanned readmissions or complications, which not only would drive a negative member experience, but also would increase costs for the plan.
Long before the NSA and TiC regulations went into effect, Healthcare Bluebook established itself as a national leader in improving cost and quality transparency. Today, there’s no need for TPAs to feel that they must be data experts, in addition to their work adjudicating claims and supporting employers. The goal of such a partnership is to simplify healthcare – for everyone.
| Icon | Quality | Cost |
| Green | Top third of quality ratings | Fair Price |
| Yellow | Middle third of quality ratings | Slightly above the Fair Price |
| Red | Bottom third of quality ratings | Highest cost |
Expertise in Claims and Negotiation
A partner like Valenz Health brings deeper experience with negotiations and managing the complexities of out-of-network provider billing and payment expectations, along with a full understanding of the NSA requirements.
Valenz Health experts know how claims should be paid, what to include in the Advanced Explanation of Benefits, how to handle the CMS portal, and the timelines for IDR initiation – including payment, selection and delivery of the final offer. This supports TPAs in managing the open negotiation process in a timely manner – preventing unnecessary IDR initiation or acceptance of a rate to avoid IDR because there simply isn’t enough time to resolve it.
A key priority is a partner’s ability to accurately calculate a qualified payment amount (QPA), or the median of contracted rates for a specific service in the same geographic region within the same insurance market. This can pose a challenge for TPAs because it requires access to an extensive amount of data on multiple markets with many different emergency providers, air ambulance providers, and other specialty services. Because the member’s cost share is calculated off the QPA, the accuracy of the data is critical.
An ideal partner has credible experience with negotiating and adheres to the NSA rules and regulations. Negotiation efforts with providers who refuse to accept a certain payment often prove difficult and extensive. In handling those providers, a partner should know how to minimize the additional payment that’s needed or may be required to settle a claim with a QPA applied.
Access to a much deeper level of data, like that of Valenz Health, allows for more meaningful negotiations, with the ability to accurately share all the factors that ultimately led to the reasonable reimbursement rate. The NSA regulations are very clear that the rate must be the median of at least three in-network rates, and the data must be at hand to support and defend that.
Finally, the value of a highly organized partner that emphasizes strong communication cannot be understated for a TPA’s compliance efforts. To meet the extremely rigid rules of the NSA, adherence to those specific timelines is critical to prevent a default judgment in favor of the provider. From aggregating all the data and showing that good-faith negotiations were conducted, to touching on the seven data points on which an IDR entity will make its decision – an experienced partner will realize the importance of staying on top of the process every step of the way.
One Partner to Meet Every Need
It’s difficult for self-insured employers to achieve full compliance with the NSA and TIC on their own – and even when working with TPAs, the ultimate responsibility of compliance falls to them. A knowledgeable, data-centric partner will benefit everyone.
To effectively manage claims, drive savings and support a positive member experience, TPAs need to utilize everything at their disposal. Together, the Healthcare Bluebook member experience and Valenz Health focus on post-claim compliance leverage a great intersection of data. Valenz Health’s industry-leading cost and quality data sets deliver actionable insights that identify savings opportunities and guide better decisions with the following:
- Ensuring defensible, market-supported reimbursements
- Aggregating years of robust claims data from thousands of provider network cases with industry-leading sources of payment, cost and charge-based data sets together with biometrics and clinical data
- Analyzing quality, utilization and cost
- Leveraging data-mining capabilities that identify patterns and pinpoint high-performing providers with optimal cost structures
Valenz Health also stands ready to provide education for self-insured employers so they can ensure their TPAs are advocating for them appropriately. Even with support from partners like Valenz Health to manage these processes, employers must be knowledgeable enough to ask appropriate questions and play a proactive role in their compliance efforts.
For TPAs looking for simplicity rather than juggling multiple vendors to meet legislative requirements, no other company is better positioned to provide everything needed to ensure compliance with the NSA and TiC regulations. Even as legislation continues to evolve, Valenz Health will be the partner that skates to where the puck is going to solve for the challenges ahead – supporting TPAs from start to finish so everyone can focus on what they do best.
Find out more about how Valenz Health ensures compliance with NSA and TiC regulations at valenzhealth.com/no-surprises-transparency-in-coverage/ or connect with us below.