Self Funding Partner General How Employers Can...
How Employers Can Help Their Employees Avoid Balance Billing
By Deb Kunferman, VP of Provider Contracting & Relations

Out-of-network claims continually cost health plans hundreds of thousands of dollars in extra medical fees. Several studies 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 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 The Alliance focuses so heavily on adding providers to its Smarter Networks.

A Comprehensive Network for More Care Choices
Employers of The Alliance experience balance billing at a much lower rate thanks to Smarter NetworksSM. Here’s what we added to our network last year alone:
  • 8 Hospitals
  • 2 Ambulatory Surgical Centers
  • 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.

Smarter Contracting
The Alliance’s contracting staff has vast contracting experience – including working on the provider side – and they use that knowledge to negotiate beneficial contracts for our employers.

We regularly identify out-of-network providers by reviewing services rendered at providers that balance bill via claims data on a quarterly basis. Then, they determine if those providers are viable to add to our Smarter Networks.

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 – and a standard requirement in all our contracts – because it’s helping your employees stay in-network and save more money.

Reference-Based Contracting by The Alliance®
Another piece of our provider 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.

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

Steer with Smarter Health
Smart employers steer their employees to high-value providers, and The Alliance can help employers make informed decisions using Smarter HealthSM. Unlike fully insured plans, The Alliance gives employers access to their data.

Other Tools
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: We encourage our employers’ workforces 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.

Learn More About The Alliance
Contact us to learn how we can help reduce out-of-network claims for your health plan today.

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