No Surprises Act and Its Impact on Reference Based Pricing Plans

SOURCE: Multiplan

This Q&A should give a degree of comfort to those worried about the impact the No Surprise Act will have on Reference Based Pricing plans. However, one must always consider the source when coming to one’s own conclusions.

“The No Surprises Act addresses primarily emergency services, non-emergency services delivered out-of-network in an in-network facility, and out-of-network air ambulance services.  How will these services be paid by a RBP plan?”

“It’s important to understand that the No Surprises Act doesn’t prescribe how the plan pays the provider initially, only that the member can’t be balance billed.  Instead, the plan and provider must reach an agreement or take the case to arbitration. This means the plan can continue to reimburse surprise bills using the current reference-based price. Any disagreement would be handled in the same manner it is today, except instead of the member starting the process by reporting a balance bill, the process starts with the provider not being satisfied with the initial reimbursement.”

“So people don’t have to worry if they’re using reference-based pricing that they will have to go from something like 150% of Medicare to 400% of Medicare?”

“No, I don’t think so. Not on an overall basis. Some particular claims will increase. Plans will have to adopt plan language that allows them to go above and beyond their normal operating corridors on the Medicare plus pricing.”

“So if a plan pays at 150% of Medicare, and they give you the ability to negotiate up to 200%, they may need to consider raising the 200% a little higher?”

“Yes, just for the surprise bill claims where QPA is higher. In that way, the pricing still has the teeth you want it to have. You need to have the flexibility to increase reimbursement on surprisebills. This will help avoid arbitration, which no one wants to go to. Arbitration is costly for the plans — and for us.”

“There is concern that RBP plans and payment levels that are based on a percentage above Medicare rates may not be able to be sustained with the No Surprises Act.  Do you see the percentage of Medicare payments to providers increasing due to the No Surprises Act?”

“We don’t see that……We don’t see a lot of appeals from providers, even those that are “surprise billers.” But the law shines a spotlight on surprise bill reimbursement so we are expecting some pushback that we haven’t historically seen…….There will be some higher rates on some emergency bills, but we don’t believe it is substantial enough to water down the savings of RBP vendors.


How Banning Surprise Billing Changes MultiPlan’s Business

Quizzify Earns Total Victory In Surprise Bill Dispute

Providers Find Silver Lining in “No Surprises Bill”

Congress Releases Surprise Billing Compromise

Surprise Medical Bills – Two Texas Physicians Respond 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.