By: Scott Bennett and David Ostrowsky

As rising healthcare costs continue to challenge employers and third-party administrators (TPAs), Reference-Based Pricing (RBP) has emerged as a powerful strategy for cost containment. However, RBP, while promising, is not without its pitfalls. Chief among them is balance billing, in which providers charge patients for the difference between their billed charges and the RBP plan’s payment. Additionally, the No Surprises Act (NSA) has introduced Open Negotiations and Independent Dispute Resolution (IDR) processes, which, while protecting patients, expose employers to post-payment disputes. Addressing these concerns effectively requires comprehensive tools, support, and strategic implementation.

Addressing the Challenges of RBP Programs and NSA Requirements

RBP programs use reference points such as Medicare rates to create more predictable and transparent pricing. While this can reduce healthcare costs and broaden provider options, it also exposes plan participants to potential balance billing when providers reject the RBP payment as full settlement and bill the patient for the remaining balance. This creates financial stress for both patients and employers.

The introduction of the NSA further shifts the focus of payment disputes from patients to employers. Open Negotiations and IDR processes require a deep understanding of regulations, adherence to strict timelines, and awareness of critical benchmarks necessary to successfully argue, negotiate, and defend cases. TPAs and self-funded employers must navigate these processes carefully to mitigate risk and manage potential exposure.

 How Comprehensive RBP Solutions and NSA Expertise Mitigate Risks

1. Effective Balance Bill Resolution 

Choosing an RBP solution that offers strong balance bill resolution is critical. Programs that include direct intervention and independent legal support can prevent unexpected financial burdens on employees and reduce the administrative load on employers and TPAs. Care Empowered Pricing, for instance, includes this type of support, leveraging years of experience in resolving balance billing issues effectively and adapting to the evolving regulatory landscape under the NSA.

2. Expertise in NSA Open Negotiations and IDR 

Handling Open Negotiations and IDR requires more than basic dispute resolution skills. Employers need an informed and experienced team that understands the regulations, adheres to strict timelines, and recognizes the important benchmarks necessary to advocate successfully. Solutions that provide this level of expertise ensure that employers are prepared to navigate these complex processes and defend their positions effectively, minimizing exposure and ensuring compliance.

3. Empowered Provider Selection 

The use of advanced provider data and selection tools can greatly enhance the success of an RBP program. By using technology-enabled repricing engines, TPAs can glean insights into provider practices and payment acceptance, thereby steering employees toward providers more likely to accept reference-based payments without triggering balance bills. This also helps reduce the frequency of disputes requiring NSA Open Negotiations or IDR processes.

4. Member Education and Support 

Educating employees about how their RBP plan functions and how to identify compliant providers is essential. Solutions that offer real-time support and guidance ensure that members are confident and well-prepared when navigating healthcare services. Additionally, having a well-informed and experienced team capable of reacting swiftly, reaching out, and using technology based on practical experience to track and resolve cases is vital. Care Empowered Pricing emphasizes member education and continuous access to resources in order to bolster awareness of the NSA processes.

Best Practices for Preventing and Resolving Balance Bills and Navigating NSA Processes

Preventing and addressing balance billing and post-payment disputes is essential for the success of any RBP program. Key practices include:

• Transparent Communication: Offering employees detailed, region-specific pricing guides to inform their decisions and help them select providers aligned with plan terms.
• Proactive Legal Support and Regulatory Adherence: Leveraging embedded legal advocacy and ensuring strict adherence to NSA requirements and timelines to protect members and employers when disputes arise.
• Experienced Team and Technology Integration: Ensuring a team is in place that can respond effectively, leverage technology, and use experience to manage and resolve cases promptly, including those involving Open Negotiations and IDR processes.

Why Enhanced RBP and NSA Solutions Matter

For TPAs and self-funded employers, selecting an RBP solution that encompasses customizable pricing, experienced advocacy, and continuous member support—while also incorporating expertise in NSA regulations and dispute resolution—is essential. Solutions like Care Empowered Pricing deliver comprehensive approaches, ensuring that participants are informed, supported, and protected from balance billing challenges and that employers are well-equipped to handle post-payment disputes. This creates a more sustainable, efficient, and fair approach to healthcare pricing and compliance that benefits all stakeholders.

By integrating these strategies into their RBP programs, TPAs and employers can enhance participant experiences, reduce financial risks, and build a healthcare framework centered on transparency, fairness, and robust regulatory compliance.