Reference Based Pricing, Individual Responsibility & Willing Providers


By William Rusteberg

Reference Based Pricing with limited balance billing advocacy and legal defense services is the “grown-up” way of offering employer sponsored health insurance.

We have all been worried about the effects of balance billing…………..upset employees, lawsuits, dinged credit, etc. But, if an employer educates his workers (Ah yes, just another chore for HR), for the first time plan participants will  understand that they have skin in the game. It’s called individual responsibility……………money affects behavior.

Balance billing advocacy and legal representation could continue to be important for emergency hospital admissions, while non-emergency services can be shopped for the best pricing and outcomes. Hospital bill audits would continue to be an important part of plan management, fulfilling fiduciary duties through prudent business practice.

There are service providers active in this market and more to enter, we expect.

The future, we believe, is in direct contracting with a limited number of willing providers at rates that are more attractive to providers than government reimbursement rates, yet less than the sometimes exorbitant managed care rates we see routinely. Proprietary panels of providers for specific employers ensures quick and efficient access to medical care versus waiting for days and weeks to see a primary care physician, or even months for a specialist once ObamaCare takes full effect in 2014.

Employers can and should initiate direct contact with their local provider community now.