Protect - Balance billing Resolution

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Balance Billing Resolution FAQ's

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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 to 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 to select health benefit plans its Balance Bill SafeGuard program.  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.

No Surprises Act (NSA)

The Phia Group’s No Surprises Act (NSA)’s service, offered to users of both Unwrapped and Balance Bill SafeGuard, includes support for both payment and open negotiations as well as formal dispute resolution triage and navigation. With years of experience in balance bill resolution, litigation, and nationwide negotiations in complex regulatory forums for hundreds of clients, The Phia Group can provide NSA payment analysis and recommendations including an initial payment, QPA support, and multiple factors to utilize in open negotiations such as quality, costs, and credible transparency data from payors and providers to show comprehensive claim level benchmarks. A thorough review of your stop-loss policy regarding excluded expenses is also provided.

Additionally, The Phia Group can provide IDR timeline tracking, procedural challenges and orientation in a complex process; as well as offer support leading up to and through the entire process, leveraging real-word experience in the IDR portal and contact with Independent Dispute Resolution Entities. With its extensive team of staff attorneys, domain knowledge, clinical auditors, certified coders, and data analysts, The Phia Group can help you efficiently strategize and timely respond to the unique standards for cost containment and defense set by the NSA. In addition to our core services, we also provide a comprehensive analysis of OON and wrap network claims to help you create an NSA-driven strategy that works for you.