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Perhaps no healthcare professional understands the gravity of non-compliance by self-insured health plans better than third-party administrators (TPAs).
As the individuals often tasked with the responsibility of meeting No Surprises Act (NSA) requirements and Transparency in Coverage (TiC) rules, TPAs play a key role in helping self-funded plans stay compliant — a monumental task in today’s ever-changing healthcare ecosystem.
But they don’t have to do it alone.
By teaming up with Vālenz Health®, TPAs not only receive direct, personalized support from an organization well-versed with compliance matters. They also get access to the most comprehensive cost and quality data available, as well as the ability to expertly navigate and execute all aspects of claims services affected by NSA and TiC regulations.
The result: Higher satisfaction from self-funded employers, better client retention, and smarter, better, faster healthcare for all involved.
How the Industry-Leading Solutions from Vālenz Health® Help Ensure NSA and TiC Compliance
As an industry leader in innovative healthcare solutions, Valenz is uniquely positioned to meet the legislative requirements of protecting patients from surprise medical bills and providing easily accessible information on the true costs of care — all offered as part of a single integrated platform.
What that means for your self-funded clients:
- Better price and data transparency
- Higher member engagement and smarter care choices
- Improved efficiency in managing out-of-network claim processes and payments
- Minimized likelihood of costly independent dispute resolutions (IDRs)
Member-Facing Tools for Better Transparency
The TiC rulings from 2020 make it clear: All healthcare plans and issuers must disclose price and cost-sharing information to plan participants, beneficiaries, and enrollees.
Valenz Bluebook does that heavy lifting — so TPAs and members don’t have to.
With an extensive claims data set at its fingertips, Valenz Bluebook integrates both cost and outcomes 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.
The goal: Engage members early and often, giving them access to necessary, helpful information as they search for procedures and providers, even before they have received care.
Valenz Bluebook leans heavily on historical claims data to guide members to the right provider/facility for the right care at the right price, a designation we call “Fair Price.” In doing so, the platform fulfills the legal requirement to share specific pricing, while also protecting the member experience by paving a clear path to the lowest-cost, highest-quality care option.
And while TiC regulations don’t require the inclusion of quality data, Valenz Bluebook goes the extra mile to include it — because it plays a significant factor in cost determination, too.
By strategically layering the quality component into the pricing equation, Valenz Bluebook decreases the likelihood of unplanned readmissions or complications — situations that not only drive negative member experiences but also increase total costs for the plan.
| 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 |
With this approach, Valenz Bluebook long ago established itself as a national leader in improving cost and quality transparency — years before NSA and TiC regulations went into effect. As a result, today’s TPAs can trust Valenz to be the data expert on their behalf, allowing them to focus solely on what they do best: adjudicating claims and supporting employers.
The goal of such a partnership is to simplify healthcare — for everyone.
Expertise in Claims and Negotiation
With the IDR management process estimated to cost $5 billion over the last few years alone, TPAs need an expert by their side to not only manage any IDR processes that emerge but, even more importantly, to also avoid IDR risks with proper payment integrity solutions from the start.
In addition to their full understanding of NSA requirements, the Valenz Payment Integrity team uses their deep experience with negotiations and the complexities of out-of-network provider billing and payment expectations to take the burden off TPAs’ shoulders, handling:
- The claims payment process, including CMS portal navigation
- The open negotiations process, including calculation of qualified payment amounts (QPAs) and rate acceptance within a timely manner
- IDR initiation, including payment, selection, and delivery of the final offer
QPAs regularly pose challenges for TPAs due to the extensive amount of data required — data pulled from multiple markets with multiple emergency providers, air ambulance providers, and other specialty services. The wealth of data in the Valenz Bluebook solution removes those challenges, ensuring unparalleled data accuracy for efficient negotiations that minimize any additional payments needed to settle claims.
This means more reasonable reimbursement rates, backed by a deeper level of data that supports and defends the negotiation.
From aggregating all 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, Valenz understands the importance of meeting the NSA's rigid rules and timelines every step of the way — and provides all the support TPAs need during the compliance process to ensure favorable outcomes for your self-funded clients.
The solution can be found in our Valenz Bluebook Comply and Out-of-Network (OON) Repricing bundle, which offers NSA compliance protection and cost containment in a single, proactive strategy. By combining our full compliance suite with data-driven, defensible reimbursements, Valenz delivers an average 67% savings, less than 1% provider appeal rate, and rapid turnaround to take the administrative and financial burden off your shoulders.
Learn more by contacting our team members today.
One Partner to Meet Every Need
It’s extremely difficult for self-funded employers to achieve full compliance with the NSA and TiC on their own, even when working with knowledgeable and helpful TPAs.
To effectively manage claims, drive savings, and support a positive member experience, TPAs need to use every tool at their disposal — and that includes a third-party, data-centric partner like Valenz.
The Valenz integrated platform combines both member experience and post-claim compliance to leverage a greater intersection of data, delivering actionable insights, identifying savings opportunities, and guiding better decisions by:
- Aggregating years of robust claims data from thousands of provider network cases using industry-leading sources of payment-, cost-, and charge-based data sets, as well as biometrics and clinical data
- Analyzing care quality, utilization, and cost
- Leveraging data-mining capabilities that identify patterns and pinpoint high-performing providers with optimal cost structures
- Ensuring defensible, market-supported reimbursements
As part of our mission to simplify healthcare for all, Valenz doesn’t just provide support to TPAs, either. Our team also educates self-funded employers about the compliance process, ensuring they are knowledgeable enough to ask appropriate questions, confirm that their TPAs are advocating for them appropriately, and otherwise play a proactive role in their compliance efforts.
Deliver Better Compliance Solutions with Vālenz Health® Today
If you’re a TPA who’s tired of juggling multiple vendors to meet legislative requirements, it’s time for a simpler approach — the seamlessly integrated platform from Valenz.
In addition to providing all the services you need for full NSA and TiC compliance, Valenz offers an end-to-end solution suite that optimizes the utilization of high-value healthcare across the entire member journey.
By integrating cost containment and member engagement in ValenzONE, we connect patients with high-quality, lower-cost providers and health systems to deliver measurable savings to plan members, self-insured employers, and the TPAs and brokers who serve them. This represents our latest innovation in creating smarter, better, faster healthcare for all.
As compliance legislation evolves, Valenz will remain the partner that skates to where the puck is going to solve for the unseen challenges ahead — supporting TPAs, brokers, and, most importantly, the members at the heart of the plan from start to finish.
Find out more about how Valenz ensures compliance with NSA and TiC regulations by connecting with our team below.