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Nov 27, 2019

While many out-of-network (OON) providers charge reasonable prices for their services, insurers must also cope with excessive OON charges, which undermine members’ financial security and fuel rising healthcare costs. What percentage of these claims should be paid, and how can insurers better protect their members from debilitating balances?

On today's show, Marcus James, Senior Vice President of Claims and Membership for Arkansas BlueCross BlueShield, joins Nanci Ziegler, Vice President of Strategic Clients at Change Healthcare, to discuss what goes into developing a successful OON strategy, how a comprehensive approach can benefit members and providers, and why payers should take a hard look at their current OON approach.

Here's what they covered: 

  • Non-par providers and what defines an out-of-network claim (01:18)
  • Two growing problems: surprise balance billing and ER pricing at walk-in clinics (02:23)
  • Why balance billing vs. paid-in-full OON claims is a lose/lose proposition (03:53)
  • The impact of an OON strategy on combating excessive OON claims billings (05:26)
  • Arizona BlueCross BlueShield conditions for out-of-area OON rate negotiations (06:49)
  • What's an Integrated Repricing Network, and how much of the country can it cover? (09:00)
  • Protecting members by preventing balance billing on 20-25% of OON claims (10:23)
  • How to give faster reimbursement and other benefits to OON providers (11:55)
  • Where an OON strategy becomes a value-added service for employer groups (13:07)
  • Payment integrity innovations to reduce provider abrasion (14:10)

Episode Resources

  1. Marcus James' bio
  2. Nanci Ziegler's bio
  3. Unraveling Out-of-Network Surprise Medical Bill Legislation
  4. Integrated Repricing Network
  5. Payment Accuracy Solutions

Show Resources