this No Accident Act (NSA) Effective on January 1, 2022. We know what this means for patients-unexpected medical expenses due to conditions beyond their control, which is a welcome probation. But what about other stakeholders, such as insurance companies? A provision of the No Accident Act requires health plans to update their provider list more frequently. This is the root cause of accidental billing, that is, patients can easily identify which providers are in the network. If the payer can update their catalog in as little as 48 hours, as required by law, patients will have a better chance of finding the care actually covered by their plan.
Sounds reasonable, right?
Except for the fact that health plans process large amounts of provider data at any given time. And data will not flow seamlessly through the sharing platform between the payer and the provider. The payer actually receives Excel spreadsheets from hundreds of different provider groups, each with its own unique and constantly changing template. The data is so messy that all plans have full-time staff, their job is to evaluate, explain, clean up, and then enter it into the planning system. Not surprisingly-puns-these updates can take weeks, cost millions of dollars a year, and the accuracy rate is still as low as 60%. This is a big problem, because the plan not only relies on this information to update their provider catalog, but also determines which providers should pay contract rates, professional and license updates, and billing information changes needed to properly pay claims .
Although historically it has been challenging for payers to solve all these problems, the latest advances in machine learning and artificial intelligence now make it possible to spend millions of hours every year cleaning and typing these data automatically, and improve its accuracy. Think of it this way: gardeners have machines to help them shovel soil, so they can focus on making the yard beautiful. To give another example of an industry that concerns human life, all flight decisions are made by pilots, not airplanes.
These are two examples of technologies that help humans perform large amounts of work safely and easily. If they plan to use these technologies, they will not only comply with the No Accident Law, but they will also have the right to return employees to their core business: keeping members healthy.
How should payers consider automation
In the next few months, when health insurance companies consider using automation to help them comply with the No Accident Law, there are three main things to keep in mind.
- Understand what automation can and cannot do. Automation cannot completely solve the problem of global interoperability. However, what some more complex platforms can do is to intervene between different systems and act as translators. If the plan is to pre-encode the knowledge possessed by the staff, this knowledge has been cleaning and typing this data, and then this knowledge is provided to the algorithm, then it can undertake the work related to understanding the data. More simply, if an automated tool has all the information about how humans make decisions about processing this data, then it can apply the same decision-making framework, but in a more effective and consistent way.
- Evaluate the situation and set realistic goals. Under the current manual process, how long is the average time for payers to update their providers? What percentage of updates are accurate? What types of problems do you encounter most often when planning to receive data (are you missing column headings and/or blank fields in the Excel file, listed providers in the wrong place of practice, or other problems altogether)? The answers to these questions vary from payer to payer, and the improvement goals are also different. Compared with the plan specifically for the single market, the national plan clearly received more data from providers. Some plans have begun to document their data processing decision tree, while others have not even determined the need for this file. Further health plans may wish to set goals that exceed the requirements of the No Accidents Act. The goal is to reduce the turnaround time for provider updates to 24 hours (instead of the required 48 hours) and an accuracy level of 95% or higher. Given the power of the automated tools available today to solve this problem, these are reasonable goals.
- Understand the range of automation solutions available. Not all automation solutions are created equal. Some require a “dismantle and replace” method. The payer may find that this method will cause damage to the existing IT infrastructure, but other solutions can actually coexist with the current system. Solutions also differ in the types of data they can automate—insurers should look for solutions that are complex enough to deal with the chaos inherent in manually generated data. Finally, the payer should look for an automation partner who provides human support in addition to technology. There is no need to have a team of data scientists in-house to take advantage of automation. The right partner can assist with needs assessment and goal setting, provide guidance on how to document the current manual processes, set expectations around the implementation of an automated timetable, and of course, speed up the timetable.
January 1, 2022 seems to be far away, but considering the upcoming holidays and people usually take vacations in the fourth quarter of this year, the deadline for the “No Accident Law” is actually approaching. Payers who wish to comply with the provisions of their provider directory must take immediate action.
Photo: Fitzquez, Getty Images
