We hosted employers for an action-packed hour to talk about how you can guide your employees to avoid costly balance billing. If you missed the webinar, you can view the recording or read on for a detailed recap of this important topic.

Out-of-network claims continually cost health plans hundreds of thousands of dollars in extra medical fees. In fact, several studies – like this one – show that roughly 20% of patients with employer-sponsored health care coverage incur balance billing. Let’s explain how to avoid these common, costly issues from happening to you.

What’s Balance Billing?

Balance billing happens when an employee or family member receives care outside their network. The out-of-network provider can hold the patient – your employee – responsible for the difference between the amount the provider charges and the amount the health plan allows for that service.

In-network providers can’t balance bill, which is why we focus so heavily on adding providers to our network for employers.

Smarter Contracting Creates Smarter NetworksSM

The Alliance greatly minimizes the chances of your employees experiencing balance billing thanks to our expert provider contracting and relations staff. We have four contractors with vast contracting experience – including experience working on the provider side – and they use that knowledge to negotiate beneficial contracts on your behalf and avoid balance billing. We regularly identify out-of-network providers by reviewing services rendered at providers that balance bill via claims data on a quarterly basis. Then, we determine if those providers are viable to add to our Smarter Networks.

It’s important to note that if a provider is on this list, it does not necessarily guarantee The Alliance will contract with them. We have an extensive and thorough vetting process to determine if a provider is viable to add to our network, because at the end of the day, we know we’re committing them to our employers who pay them.

Providers need to agree to stringent rules and requirements to contract with The Alliance, including a longer standard contract period; they must remain in-network for two years. Our contracts are evergreen, which means the contract automatically renews after two years unless either party wishes to end the relationship.

The Alliance is proud to have long-standing provider relationships; it’s a very rare occurrence for a provider to terminate their contract with us.

Reference-Based Contracting by The Alliance®

Another piece of our vetting process is through Reference-Based Contracting. We contract with providers using Medicare as a basis for reimbursement to protect our employers from large increases in provider charges. This type of payment reform by The Alliance is used in over 80% of our contracts.

Why is this important? Paying providers based on a percent of Medicare doesn’t just give us an appropriate benchmark by which we can measure relative value, it improves your employees’ access to High-Value Health Care while enabling you to use innovative benefit plan design.

Less Balance Billing = More Savings

Once a provider is added to our network, there are protections in our contracts that state they must refer to other in-network providers. This is a significant inclusion because it’s helping your employees stay in-network and save more money, and this protection is a standard requirement in all our contracts. (If for some reason this isn’t happening with your in-network provider, please let us know. We will work with the provider and ensure they have the education and resources necessary to refer to other in-network providers.)

A Comprehensive Network for More Care Choices

As we’ve covered, 15-20% of patients experience balance billing, however, employers of The Alliance experience balance billing at a much lower rate thanks to custom provider networks. Here’s the providers we added to our Comprehensive Network last year:

  • 8 Hospitals
  • 2 Ambulatory Surgical Centers (ASCs)
  • 116 Mental Health Providers
  • 32 Chiropractors
  • 207 Medical Clinics

Today, our provider network encompasses more than 34,000 doctors and health care providers, and as part of our mission – to move health care forward for employers – we continually add to this extensive network.

The Alliance actively listens to its employer-members through meetings, events, and surveys, which is why we added more than 100 behavioral health providers to our network in a single year; we do our best to ensure we add the right providers to our network on your behalf.

Balance Billing At The Legislative Level

There’s been a lot of federal visibility centered around balance billing today, and for good reason: 1 in 5 Americans experience balance billing on elective surgeries. This increased legislative focus culminated in the No Surprises Act, (part of the Consolidated Appropriations Act). This federal legislation protects both patients and plan sponsors.

How does it protect employees from balance billing? Any patient that receives out-of-network care will not have to cost-share more than had they received care from an in-network provider.

How does it protect employers from balance billing? When the claim is paid for out-of-network services, they are priced at a “usual and customary reimbursement methodology,” and the provider is not allowed to balance bill.

There’s also some rules and regulations around hospitals and ASCs. When a patient goes in for surgery, providers are required to advise patients of their rights, including that the patient cannot be balance billed.

Even so, The Alliance believes its best to have a contract to avoid balance billing, and the best strategy is to bring out-of-network providers to an in-network status. We don’t want to rely on a bill that could be changed or disputed – we would rather add providers to our network so nobody has to experience balance billing.

Steer with Smarter Health

Smarter Health Analysis is another way The Alliance helps our employers make better health care decisions. Unlike fully insured plans, The Alliance gives you access to your data. One way you can use this data is to steer your employees to high-value providers. While we know avoiding balance billing is a consumer issue, we want to make sure our employers are looking at their data and listening to their employees to try and contract with these out-of-network providers.

If there’s an issue, please let us know! You may hear that an employee needs specialty care, or that a family member is having access issues. If you let my team know, we can help you find solutions. We do it every day.

Other Tools to Help Your Employees Avoid Balance Billing

Lastly, employee education is absolutely essential when it comes to avoiding balance billing; the less out-of-network care provided means lower costs and higher coverage levels for your employees and their family members.

Always Ask: The simplest way to avoid balance billing is for the patient to ask for a cost estimate when visiting with a provider. We also recommend that employees match up that estimated cost with the amount actually incurred from the invoice and see if it matches up with the payment rendered by the health plan.

Flyers: The Alliance has developed some one-page resources on balance billing – in several languages – for you to distribute to your workforce and help them avoid balance billing.

Find a Doctor Online Tool: Employers of The Alliance should encourage their employees and their family members to always use Find a Doctor when seeking medical care. They can access it on both desktop computer and their mobile phone, and they can sort their in-network search by clinician name, specialty, facility name, or facility type. It’s the easiest way to avoid balance billing!

Not finding your preferred provider on Find a Doctor? Refer them to our network by filling out our Provider nomination form.

It’s great to share these educational resources with your staff repeatedly throughout the year at workshops, health fairs, employee engagement events, newsletters, town halls, direct mail etc. The higher the frequency, the more success you’ll likely have!

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Deb Kunferman

Deb Kunferman

Vice President of Provider Contracting & Relations

Deb Kunferman joined The Alliance in 2013 and now serves as Vice President of Provider Contracting & Relations. Kunferman leads the team responsible for constructing a provider network that brings value to employer health care purchasing by providing direction and oversight of provider network development strategies, including maintaining and growing provider partnerships.

Kunferman previously served as CEO at Cumberland Memorial Hospital where she oversaw the fiscal budget, 26 departments, and 285 employees. Other prior roles include CEO at Oakleaf Surgical Hospital and Executive Director for Valley Health Plan, an insurance plan in Eau Claire, WI.

Kunferman earned her Master’s degree at the University of Wisconsin–Eau Claire and has served on several Boards in the Eau Claire community over the course of her career, including United Way and Children’s Service Society, and she was elected as the first female president of Kiwanis Club in the organization’s 42-year history.

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