Protect - Patient Defender & Balance billing

Patient Defender Flyer
Patient Defender FAQ's
Balance Billing Support Flyer
Balance Billing FAQ's
Balance-Billing: What Patients Need To Know
The No Surprises Act Explained

Patient Defender

For years, The Phia Group has been helping you Learn, Plan, Save, and Protect. Now, with Patient Defender, we’re expanding that protection to patients!

For those of you who have experienced balance-billing, you know what a pain it can be to employees. Now, thankfully, there is a way to ensure that the patient has legal counsel at their disposal, pre-paid and ready to defend the patient against balance-billing and collections activities.

With Patient Defender, a small PEPM rate ensures that a trusted law firm is available, ready and willing to assist the patient when balance-billing rears its ugly head. This can help benefit plans, TPAs, and brokers continue to contain costs while knowing that patients have a legal advocate standing by.


Balance-Billing Support

Reference-Based-Pricing, or “RBP,” is a term used by many in our industry to describe any claim pricing methodology grounded in the 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 the 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. Phia 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%!