Selecting the right health insurance provider is a critical decision that can significantly impact your healthcare costs and access to quality care. Reference-based pricing (RBP) is gaining popularity because of its unique approach to healthcare cost management, allowing employers to contain costs, analyze their data, and better predict their future spend. However, choosing the best RBP medical insurance provider requires careful consideration.
Since its birth in 2007, the RBP model has attracted many Program Administrators throughout the United States. As with any product/service we purchase, there are “bad actors” to look out for. The RBP space is unfortunately no different. In this article, we will provide insight into the key factors to consider when selecting a best-in-class RBP medical insurance provider.
Understand the Basics of RBP
Before diving into the selection process, it's crucial to understand the fundamentals of reference-based pricing. In an RBP plan, the insurer determines the allowable amount for a medical service or procedure based on a reference point, such as Medicare rates. Patients may be responsible for the difference between the reference price and the actual charge. A good RBP provider will provide a contractual obligation to resolve any balance billing issues on behalf of the plan's members. This is a crucial and necessary requirement of the agreement. Without this protection, your team members and potentially your organization can be held responsible for the payment of balance bills.
Provider Network
In an RBP program, the focus on savings is at the facility level - hospitals and surgery centers. When it comes to employees visiting a PCP or specialist office, the focus turns to access and ease of use. Unlike traditional insurance plans, RBP plans often do not have a fixed network of healthcare providers. Instead, they rely on the principle of “any willing provider.”
It is important that your RBP provider has access to a national “Provider-only” network and has a structured and well-run process for negotiating one-off agreements with providers that are not in the network. If your RBP program does not offer a provider-only network and the administrators are not diligent in their efforts to contract with your desired doctors, you can potentially have unhappy employees.
Cost Transparency / Audit Process
RBP plans are designed to promote cost transparency. Look for an RBP provider that provides clear and accessible information about the reference prices for various medical services and procedures. This includes the audit process that they agree to adhere to. Sadly, the majority of hospital bills are riddled with errors and egregious charges. The success of your RBP program will rely heavily on your provider's ability to obtain, analyze, and adjust itemized hospital bills at an accurate and fair cost.
Negotiation Expertise
Since RBP plans often involve negotiating prices with healthcare providers, it's crucial to choose a partner with expertise in this area. An experienced RBP provider will have a track record of successfully negotiating fair prices for medical services, ensuring that you receive quality care at reasonable costs.
Appeals and Dispute Resolution Process
Despite the best efforts of RBP providers to negotiate fair prices, disputes can sometimes arise between facilities and insurers after emergency care is administered. Ensure that the RBP plan you choose has a robust appeals and dispute resolution process in place. It is also important that your reinsurance contract coincides with your desired dispute process. An employer does not want their reinsurance contract to restrict them from a desired settlement or, even worse, release the reinsurer from an obligation to pay a claim.
Customer Support
Excellent customer support is essential when dealing with any type of insurance. Look for an RBP medical insurance provider that offers responsive customer support to address your questions and concerns promptly. A dedicated support team can make the difference in your overall experience with the plan. Require at least 3 client references in your local area!
Financial Stability
Evaluate the financial stability of the RBP insurance provider. Ensure that the company has a strong financial track record and the ability to cover your healthcare expenses. You can check their financial ratings with reputable agencies to gauge their stability.
Cost-Sharing and Coverage
Examine the cost-sharing structure of the RBP plan, including deductibles, copayments, and coinsurance. Be sure to determine the actuarial value of each plan you install. Understand what services are covered and any exclusions. It's essential to choose a plan that aligns with your healthcare needs and budget.
Selecting the best reference-based pricing medical insurance provider involves careful consideration of various factors. Unfortunately, the traditional health insurance model has proven year after year to be unsustainable. Employers must take action and consider an RBP model in order to provide their employees with a real medical benefit.
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