Full Network Replacement

Traditional program structure for reference-based pricing has included a physician-only network coupled with a vendor capable of auditing and applying revised pricing to facility claims. Aside from the confusion created at the member level as to whether they have a network, we are seeing trends making utilization of physician-only networks challenging. The best course of action in this evolving space is to eliminate both the facility networks and the physician network and leverage a comprehensive RBP program for total network replacement.

Physician-only networks and ancillary facility networks were appealing to the early adopters of RBP going back a decade ago. Providing a safety net for brokers and the plan sponsor was necessary to drive business because of the unknowns associated with the novel approach. These were viable backbones to solve access concerns on low dollar claims in the early years. Unfortunately, we have watched the systematic dismantling of physician-only networks and ancillary facility networks as they are purchased by the major managed-care organizations and shut down almost immediately. This has put holes in the safety net.

Another tactic cutting at the fabric of physician-only networks is a more recent trend. Facilities are creating procedures to identify health plans with ID cards displaying these networks and flag the member as a participant in an RBP plan, refusing to accept the physician-only network offering within its network contract. ClaimDOC’s process to engage providers on the front end of service has allowed us to navigate these circumstances without impacting members; however, it puts another checkmark against reliance on these networks for the industry as a whole.

Years ago, the ClaimDOC program was designed to be a total network replacement because I didn’t want to be reliant on what appeared to be a vulnerable product. Creating a sustainable reference-based pricing program meant building the capability to effectively provide a total network replacement solution. Our program has always supported access to physician services and the pricing of physician claims outside of a physician-only network. We have also always provided balance bill support and defense of such claims since day one.

The total network replacement strategy is going to be scary for some, yet likely will lead to progress in our industry. From a long-term sustainability perspective, we believe total network replacement will prove to be a good thing for our plans and their members. The discussion with medical providers through upfront education on the program becomes simpler and more transparent, which fosters better relationships. The old adage of techniques and methods change while concepts and principles endure is true once again. The initial reasoning behind embarking on an RBP employer-sponsored benefit platform is just as prudent, responsible, and necessary today as it always has been. However, innovation is essential in order to enjoy what the concept of RBP was intended to produce long-term.