Surprise Medical Bills & Reference Based Pricing

The old saying “The plan pays what it’s going to pay, nothing more and nothing less” will now have to necessarily say “The plan pays what an outside arbitrator says it will pay, nothing more and nothing less.”

By Bill Rusteberg

Does the “No Surprise Billing Act” legally transfer balance billing risk from RBP members to the plan sponsor (who is the insurer of a self funded plan) ?

The old saying “The plan pays what it’s going to pay, nothing more and nothing less” will now have to necessarily say “The plan pays what an outside arbitrator says it will pay, nothing more and nothing less.”

RBP plans have no network so all claims are “out-of-network.” Therefore all claim reimbursement risk is not limited by plan document language anymore but instead subject to external arbitration.

Will RBP plans become an open money pit for arbitrated claim reimbursement? We all know who has the big bucks, and it’s not plan members.

How will stop loss policies accommodate this additional risk exposure? What other implications are there for RBP Plan sponsors to consider?

Excerpt from article:

Once the law takes effect, “it’s completely irrelevant whether an emergency room doctor is in network or not,” he said. “For all intents and purposes, that doctor is in network. The patient will pay the in-network cost sharing and there is a price the provider has to accept, and the insurer has to pay.”

https://www.npr.org/sections/health-shots/2021/10/14/1045828215/surprise-medical-bills-law-health-insurance

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