Balance Billing Resolution

Protect - Balance Billing Resolution

Balance Billing Resolution

Reference-Based Pricing, or “RBP,” is a term used by many in our industry to describe any claim pricing methodology grounded in analysis of an objective value, and paying some multiple of that value, for medical services rendered. Popular parameters used for RBP include Medicare pricing (which is perhaps the most widely used), the provider’s reported costs, average wholesale price, and others.

RBP is generally applied to non-contracted claims. Rather than calculating the average charge of providers in a geographic area or using a similar methodology, a health plan utilizing RBP instead pays claims based on a percentage of what Medicare would pay, the actual cost to the provider, etc. No matter which method of RBP is used, the savings are generally significantly better than the average PPO – but there is potential for balance billing and member noise, which can be managed with help from the right partners.

Balance billing occurs when a provider does not agree with the RBP methodology of payment they receive from the Plan. Although the provider recognizes that the Plan has fulfilled its monetary obligation, it will sometimes pursue the patient in an attempt to collect the outstanding balance. The Phia Group has many strategies and arguments in place to combat such efforts from the provider. While balance billing can create noise, the average amount of our clients' total claims which result in a balance bill is only 2%!

In addition to unrivaled levels of protection afforded by The Phia Group to the benefit plan, Balance Bill Resolution also provides the plan participants access to independent legal counsel. By assigning patient defense to the plan participant, providers cannot easily bypass The Phia Group and pursue the patients directly. This further bolsters The Phia Group’s ability to resolve balance bills.

Balance Bill SafeGuard

Taking plan defense to the next level, The Phia Group offers its Balance Bill SafeGuard program to select health benefit plans. The Phia Group’s SafeGuard service is a coordinated process ensuring that balance bills are contained, and payments are capped. Available for all plan designs, upon comprehensive review and approval, and financially backed by an industry-leading A.M. top-rated reinsurance market, SafeGuard integrates PACE and Balance Billing Resolution to produce guaranteed results. With the included “Phia Guarantee,” benefit plans will never pay more than a fixed amount. Additionally, SafeGuard includes all No Surprises Act (NSA) support services available from The Phia Group.