October 26, 2023Navigating Out-of-Network Healthcare Costs: Unpacking Factors that Impact Pricing

In the ever-evolving landscape of healthcare pricing, a pressing question emerges: How will out-of-network (OON) healthcare costs be impacted by contemporary regulations and economic circumstances? The question is fair, yet complex, as there are many influential factors with the potential to increase or decrease costs – from legislative shifts such as the No Surprises Act to competitive dynamics among doctors and hospitals.

In this blog, we will explore the factors that could increase costs and those that could decrease them, giving you a comprehensive overview of what forces may shape forthcoming healthcare costs.

Exploring Potential Catalysts for Escalating Prices

A pivotal trend of note is the continual escalation of overall medical costs. Annually, medical care gets more expensive, a phenomenon that inevitably affects OON claims as well. The lack of conventional contractual safeguards puts individuals receiving care at an out-of-network provider at risk, making them vulnerable to larger bills.

Common factors for this are:

  • Balance Billing: Occurs when an OON provider bills the patient for the difference between the provider’s charges and what the insurance plan is willing to pay.
  • Emergency Care: In emergency situations, patients are often treated at the nearest medical facility regardless of whether it is in-network or OON.
  • Limited Coverage: Some insurance plans may offer no coverage for OON care except under specific circumstances.

To navigate this effectively, having an adept understanding of OON claims and recent legislation relating to OON claim payments is crucial. Without a comprehensive grasp of how they work, health plans risk spending more on these claims overall. This situation is further complicated when it comes to negotiated discounts on OON claims, as these discounts are not covered by the No Surprises Act due to them being predetermined. Consequently, if one agrees to these terms during a legal process or when figuring out a fair price under the No Surprises Act, one may actually end up paying more than they should. All of this complexity emphasizes the need for a smart and judicious approach to handling OON claims.

In the best interest of the payer, proactively securing pre-negotiated agreements with providers through diverse OON partnerships is a prudent step. This strategic approach can provide Payers with a valuable layer of protection and clarity, helping them navigate the complexities of OON claims more effectively.

Potential Paths to Decreasing OON Prices

Conversely, within the realm of OON healthcare pricing, there are also potential factors capable of curbing these claim prices. Recent transparency regulations have ignited a shift towards increased openness in the healthcare sector. These regulations necessitate hospitals to divulge their reimbursement rates from diverse Payers for various procedures, even disclosing the precise rates negotiated with each insurer. Similarly, health plans are mandated to reveal the fees they remit for procedures at different healthcare facilities. This newfound transparency dismantles the opaqueness that previously veiled pricing negotiations.

Equipped with this information, both providers and Payers are empowered to make more informed decisions, infusing the competitive landscape with new vigor. Hospitals become cognizant of the rates charged by their peers for analogous services, fostering intensified competition among healthcare providers. This in turn compels them to offer competitive pricing in a bid to attract patients and secure Payer contracts.

Some doctors or hospitals might see that they are charging much less than others, and this could incentivize them to raise their prices to match. Conversely, hospitals with above average costs may be incentivized to lower their prices when they realize what competitors are charging. In addition to this, Payers have the potential to make a difference by negotiating better deals with providers. If a large organization states that they have to be charged the same as smaller companies, providers might have to agree. This dynamic has the potential to push prices downwards, particularly within the purview of major insurance companies.

However, despite this newfound clarity, the ultimate impact on OON claim prices remains uncertain. Both sides are now using information to make decisions, and because of this, it’s hard to predict what will happen with OON claim prices. In this evolving environment, understanding the potential factors that could lead to lower OON claim prices is essential for stakeholders navigating the complex landscape of healthcare economics.

Empower Your OON Strategy with MacroHealth

As we navigate the intricate maze of OON healthcare pricing, one thing becomes abundantly clear: the landscape is far from stagnant. The delicate interplay between regulations, economic forces, and the strategies of both Payers and providers paints a picture of uncertainty. However, armed with knowledge and the right tools, it’s possible to steer through these complexities and make informed decisions.

To bypass the concerns raised by the shifting tides of OON pricing, a comprehensive strategy is key. The MacroHealth Intelligent ExchangeTM platform empowers Payers to deftly maneuver the intricate web of healthcare rules and requirements, from Price Transparency regulations to the Federal No Surprises Act. By providing seamless access to both internal and external market data, coupled with industry-standard interoperability, MacroHealth equips Payers with the means to transform healthcare access, curtail claims and administration costs, and ultimately elevate the quality of care delivered. Embracing a comprehensive OON strategy fortified by secured discounts also safeguards your plan from unnecessary administrative costs, and with the assurance of secured discounts, the claim-by-claim administrative burden of the No Surprises Act can be avoided.

With easy access to internal and external market data, in tandem with industry-standard interoperability, Payers are poised to transform healthcare access, reduce claims and administration costs, and ultimately enhance the quality of care that is delivered. With the MacroHealth Intelligent Exchange platform, you are equipped with the knowledge, insights, and tools required to navigate the ever-evolving landscape of healthcare costs. To embark on this transformative journey and explore the full potential of MacroHealth’s Intelligent Health Market as a Service (IHMaaS) solution, contact us today.

Get Exclusive Access to the MiX Platform Demo Video

Witness data-driven healthcare transformation firsthand. Request exclusive access to the MiX Platform Demo video now.

Get Exclusive Access to The Intelligent Future of Healthcare Markets

It’s time to transform healthcare markets with information technology. Fill out the form below for access to The Intelligent Future of Healthcare Markets white paper now.