Navigating Shifting Market Expectations: Enhancing OON Claim Repricing Fairness and Transparency

Navigating Shifting Market Expectations: Enhancing OON Claim Repricing Fairness and Transparency

In the changing landscape out-of-network (OON) medical claims, health plans & TPAs face the dual challenge of managing costs while ensuring fairness and transparency. A recent New York Times article spotlighting practices by certain industry players has intensified concerns regarding the management of OON claims. Such revelations underscore the importance of adopting business practices that not only meet but anticipate market expectations. Three key areas for plans to focus on are: fair repricing, balance billing support, and innovative models for repricing.

  1. Balancing Cost Containment with Fairness in Repricing:
    While it is essential to protect plans from exorbitant or erroneous charges, relying solely on simplistic or fixed pricing models and employing overly aggressive discount strategies can have negative consequences, such as tarnished reputations, increased financial burdens for members, and inflated administrative fees. Expion Health’s approach to claim repricing deviates significantly from the aggressive cost minimization tactics discussed in the article. We employ a balanced strategy through our ExpionIQ Intelligent Allowable pricing engine, which integrates a robust array of data points including FAIR Health, RAND Study data, UCR rates, geographical factors, clinical outcomes, historical data, and the potential for provider abrasion and member impact. This comprehensive approach ensures that reimbursements are not only fair but are also more likely to be accepted by healthcare providers, reducing conflict and the risk of balance bills for members.

  2. Providing Proactive Support for Members Facing Balance Bills:
    Fifty-six percent of Americans are unable to cover an emergency expense of $1,000 from their savings1, and 51% want professional assistance to resolve balance bills2. Ensuring fair payments to providers is critical in reducing the incidence of balance bills, but it is equally important to offer support to members when such bills arise. Understanding the stress and financial burden balance bills can impose, Expion Health offers proactive, concierge-level support for members who might face such charges. We inform members of the potential for receiving a balance bill and provide options through our ExpionME app. Members can choose to handle the bill independently or enlist the help of our expert negotiators, who are equipped to resolve these matters efficiently and equitably. Additionally, ExpionIQ’s dashboards provide health plans and TPAs with valuable out-of-network insights to understand the impact on members and help inform decisions such as allowable schedules and how to optimize reimbursement strategies.

  3. Exploring Innovative Solutions to Enhance Control and Reduce Fees:
    Employers and groups are increasingly vigilant about how their funds are utilized, pushing health plans and TPAs to justify their operational efficiencies and financial stewardship – forcing the adoption of a more fiduciary-like role. Forward-thinking plans and TPAs who proactively adapt will secure a competitive edge. In response, this year we introduced a groundbreaking Software as a Service (SaaS) option for our ExpoinIQ Intelligent Allowable pricing engine. This innovative tool enhances in-house pricing capabilities, offering unprecedented insights and control over the repricing process. Our volume-based pricing model presents a cost-effective alternative to traditional contingency-based models, aligning more closely with the financial and ethical interests of your business and your groups.

As market expectations shift towards greater transparency and fairness, it’s crucial for health plans and TPAs to adapt and align with these evolving standards. Expion Health is at the forefront, offering solutions that ensure compliance, enhance trust, and maintain the delicate balance between cost efficiency and fair reimbursement. By partnering with us, your business is not just keeping pace with industry changes—it’s leading the way.

1. BankRate Emergency Savings Report 2023
2. Expion Health Balance Billing Survey 2022