A Game Changer In Health Care Financing?

Effective September 1, 2020 we are trying out something new which I believe could be the future in health care financing – A cash pay centric plan coupled with a PCP referral process to the highest quality providers with the best medical outcomes.

By Bill Rusteberg

Providers are paid at the point of service in real time. The plan’s administrator handles all PCP referrals (We’ve found PCP’s are happy to give up the referral process as it’s time consuming for staff and they don’t get paid for the extra work). 


This is the illustration we used in a presentation last month followed by a brief description of how the program works. You will notice that the role and work load of the TPA is greatly diminished.


A Real Time Intercept strategy For Employers Who Use RBP As A Cost Containment Strategy

Real Time Intercept achieves meaningful engagement 60 days ahead of claims-based programs, improves patient experience and medical outcomes.  This unique strategy produces significant savings for both members and plan sponsor.

Every inbound call is an opportunity to expand cash payment savings, reduce balance bills and improve utilization of medical management and disease management programs. Only a small percentage of inbound calls will require escalation to the TPA.

Here’s how it differs from traditional TPA customer service call center routing, metrics and staffing models:

  • 24/7 “one number to call” live telephone access provided with after-hours calls staffed according to specifications by an integrated medical management partner.
  • Callers are asked clarifying questions and seek to capitalize on the value of every call contact.
  • Staff attempts to go beyond the caller’s intent to understand the broader context of the call, anticipate subsequent steps in the consumer’s healthcare journey, and identify opportunities to intervene in real time.

This Comprehensive Concierge Service is not limited to typical health plan customer service functions. It is a fully integrated consumer-focused and provider friendly concierge service that is uniquely optimized for cash-enabled RBP plans and primary care-centric models.

This unique, cash-enabled consumer-focused and provider-friendly service model will maximize cash payment savings opportunities and medical management effectiveness, particularly in collaboration with a strong primary care-centric model. This unique model can improve the consumer experience by effectively integrating balance bill prevention and negotiation into day to day customer service operations, both pre- and post-service, and for both planned and unplanned healthcare services.

This strategy will eliminate balance billing for members who “play by the rules.” For those who don’t balance billing can become an issue along with a possible need for legal representation (rare). In those cases members stand on their own on a Buyer Beware basis.

We will never know if a strategy produces expected outcomes unless we try it…………or someone else does and is willing to share the results. We will share our results at some point along the way.

RiskManagers.us is a specialty company in the benefits market that, while not an insurance company, works directly with health entities, medical providers, and businesses to identify and develop cost effective benefits packages, emphasizing transparency and fairness in direct reimbursement compensation methods.
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