By: David Ostrowsky

For over a quarter century, The Phia Group has championed a broad spectrum of cost containment initiatives to empower health plans and ultimately, their respective participants. The Phia Group believes that its latest endeavor—Care Empowered Pricing (CEP)—may be its most robust cost containment program yet. At its core, CEP is engineered to, quite simply, save plans money and as you can see below, there are a number of ways our revolutionary offering does so.

Firstly, in terms of program ownership, unlike traditional reference-based pricing (RBP) plans, in which the RBP vendor owns the program in a black box and the TPA or health plan is merely the claims administrator, CEP enables the TPA/health plan to manage the program so that it reflects their unique brand and mission. Generally speaking, many RBP vendors prioritize selling as many services as possible in a short amount of time to maximize revenue. At the same time, they utilize pricing methodologies that are meant to exaggerate savings (of which they receive a percent as their fee), without considering the likely subsequent provider backlash (coming in the form of balance billing, access denial, etc.). This overaggressive, and quite frankly, reckless approach, often leads to many RBP vendors getting acquired by competitors or even going out of business before open matters are fully resolved. Ultimately, it’s the plans that suffer most as they are saddled with a high volume of unresolved claims, the management of which can be very expensive. In contrast, with CEP, Phia collaborates with the TPA/health plan to develop a long-term strategy customized to the specific geographic area, which will produce incremental and ultimately substantial and sustainable savings.

Even if an RBP vendor is able to manage the onrush of new clients and stay in business, it is very common that once they hit their sales targets, there is a steep decline in customer service offered, leaving many plan participants/employees frustrated when experiencing lengthy delays, hassling with resultant balance bills, losing access to providers, and ultimately feeling inclined to leave their employers. With CEP, backed by a fully staffed and experienced team utilizing proprietary software for claim resolution—not to mention the additional safety net of independent legal representation—a company’s ability to retain employees is never in jeopardy because of this dynamic. In short, no claims fall through the cracks.

Because CEP is more than a simple claims pricing methodology, but instead an ecosystem of cost containment services, plans benefit from—among other features—more optimal plan design. Whereas traditional RBP programs are often bereft of comprehensive compliance reviews, CEP incorporates innovative, industry-leading plan language into its program. A failure to ensure that the applicable plan document mirrors and supports the pricing methodology is often a pitfall leading to a plan’s demise. As many RBP vendors are so intent on reducing claim costs, the ever-evolving legal and regulatory landscape can become an afterthought; such oversight can have grave financial implications with subsequent costly litigation and claim reconciliation in the years ahead. Conversely, Phia’s team of seasoned compliance experts can ensure that your plan design stays compliant with the latest developments in the healthcare law industry, as well as align with the methodologies to be applied, safeguarding you against potentially devastating financial penalties.

Lastly, it bears mentioning that the majority of RBP vendors use one system for all their clients and thus have the power to decide which providers are preferable based on their own reasons and relationships. Accordingly, such vendors have at their disposal one dimensional cost/quality provider data that is often outdated. In comparison, with CEP, Phia ensures the TPA or health plan has all-encompassing provider data that in turn is accessible to members seeking to find the most suitable providers for their needs. The goal is to transform every participant into an educated and informed healthcare consumer—balancing costs and quality—and obtaining the best care, for the most appropriate price.

True to its name, Care Empowered Pricing, with its nuanced approach toward customizing rates with plan terms, direct contracts, and provider profiles, genuinely epitomizes compassion for plan participants and their families. And there is no feature more emblematic of that sentiment than the service’s unparalleled ability to save money.