“For 2022, many TPAs are subjecting NSA claims to their ‘shared savings’ and similar programs, which could result in unexpectedly large fees….
For example, assume a participant goes to an out-of-network provider, and after the group health plan pays the claim, the provider balance bills the participant for $50,000. The TPA would then negotiate with the provider and offer to pay the provider more if the provider agrees not to balance bill the participant. If the “savings” on the claim ends up being $40,000, the TPA’s fee is a portion of the savings, often as high as 35%. In this example, the TPA’s fee would be $14,000.
[P]lan sponsors, brokers, and consultants should start asking whether applying savings programs to NSA claims is the right approach. It might be better to carve NSA claims out of savings programs or to pay a flat fee for NSA claims that is not related to the dollar amount of the claims. ” MORE >>
SOURCE: Snell & Wilmer L.L.P.
