Regulation Watch

Zelis Regulatory Efforts, Spring 2017

by Matthew Albright

Federal legislation
Through the D.C. lobbying firm Capitol Counsel, Zelis has had numerous one-on-ones with Senate staffers on the Hill to gauge the future of specific legislative issues important to Zelis and its clients. Some of the issues that we’ve discussed most recently with staffers include:

  • The EFT mandate, included in the Affordable Care Act, requires health plans to offer providers healthcare claim payments via Electronic Funds Transfer (EFT) according to specific standards and operating rules.
    • The EFT mandate is likely to survive any repeal and replace legislation over the next few years.
    • The Centers for Medicare & Medicaid Services (CMS) will most likely turn up the heat on enforcement of the EFT mandate and other HIPAA administrative simplification requirements.

(For more information on regulatory issues related to the EFT mandate, please read the Zelis white papers, The Rise and (Possible) Fall of PPACA’s Section 1104 and TPAs and the Sleeping Dragon.)

  • The Self Insurance Protection Act (SIPA) keeps state and federal legislators from defining stop-loss insurance as health SIPA passed overwhelmingly out of the U.S. House and is now in the hands of the Senate.

Tracking State Legislation
Zelis closely monitors – and, when possible, tries to influence – pending state legislation that may affect our clients or the work we do on their behalf. Examples:

Balanced Billing: Over 60 bills restricting “surprise billing” have been introduced in 26 states. An up-to-date nationwide knowledge of the balanced billing rules helps us do a better job of negotiating out-of-network claims with providers, while working with those providers to prevent them from balance billing plan members.

Provider Network Adequacy and Access: Following California’s lead in 2015 with SB 137, provider network adequacy and access legislation continues to crop up in many states. Zelis submitted concerns that the requirements in HB 311 – a large adequacy and access bill in Illinois –  were too burdensome for payers, and the subsequent amendment to the bill included changes that reflected our suggestions.

Healthcare EFT Payments: For Texas HB 1675, a bill on healthcare payments, Zelis provided amendments that would give broader choices to providers in terms of payment methods.

Ongoing Internal Compliance
Zelis continually tailors its products to conform with state and federal laws. A great example of this is our standing workgroup on provider directories that is dedicated to adjusting our processes and systems to accommodate the flood of provider directory requirements.