The Art of Persuasion – RBP is Bad for Members

Human Resources Teams are tasked with developing benefit solutions that meet many needs. They recruit new employees with competitive offerings and retain employees by meeting healthcare accessibility needs, all while ensuring the number two corporate expenditures keep the board and CFO happy.  To bring it all together, Brokers are trusted to give unbiased guidance and access to solutions. No problem, right? However, once you throw RBP into the conversation, more than likely, someone will utter the generic statement, “it’s bad for members.”

I have been with ClaimDOC for two years after spending 30 years working for the Blues and Aetna. My PPO client service experience gives me an incredible perspective on misperceptions that exist about RBP. It is professionally irresponsible to spread the narrative that RBP is bad for members. If you are tasked with advocating for members, why promote a deal-killer narrative without sufficient expertise to make that statement?

Breaking down “bad for members” – A ClaimDOC Perspective:

Poison Pill #1 – Access

How can members get seen by doctors if we don’t have a network? Moving into an open-access or network-free environment is beyond comprehension for most who haven’t participated in one. It’s crazy….ClaimDOC calls your doctors and talks to them. It’s true, one of the most revolutionary and impactful program features is simply using the phone. I’m over-simplifying, but our Pave the Way® program was developed entirely to battle member frustration with getting turned away at the doctor’s office.

If you haven’t watched our video on Pave the Way®, I highly recommend it. The reality is this is an incredibly huge undertaking. Over the past year, we have conducted 12,979 nominations at a success rate of 90.8%.

Ah, ha you are thinking. 10% of members can’t see the doctor they want. Yes, that is sort of true. However, a report would show a percentage of those requests are for specialists who don’t participate in any network or hospitals, like Mayo, that offer marginal in-network discounts. Regardless of those nuances, let’s just say 10% of your members may have to make an adjustment to their doctor of choice.

  • Quick question – What if you could get a renewal that would save you 25% if you move from one BUCAH to another BUCAH, but the disruption report showed about 10% of doctors not in the new network?
Poison Pill #2 – Balance Bills

Balance Bills are a reality with all medical plans, and anyone who tries to tell you it won’t happen is full of it. All health plans experience balance bill situations. At ClaimDOC, we see about a 3% balance bill rate. Typically these are a concentrated amount of members determined to utilize problematic providers.

Once again, what I love about our company is we don’t hide from the problem. We help our members through our Balance Bill Support Program ran entirely in-house. Members provide authorization for us to act on their behalf. A Balance Bill Specialist directly takes over all the communication necessary to resolve the dispute. With our plan language, members are not responsible for anything above their member responsibility. I cringe when I see misinformation about RBP and unknown member liability.

What never gets mentioned when pushing back on RBP is the amount of balance billing that happens within a PPO. Brokers are incentivized with bonuses and other compensation packages to push “fair renewals” from their favorite carrier and forget the flaws.

  • Quick question – Within a PPO, what kind of assistance and support programs exist on balance bills for the 4-5% of claims that are out-of-network?
  • Quick question – Do you think the transparency laws were passed because of the issues in RBP, which make up less than 5% of the market? Or do you think it was the horrendous amount of medical debt created by surprise billing that hit members of traditional networks?

A Solution that’s Good for Members

Now let me throw out some concepts that will blow your mind. Just like generically touting RBP is bad for members, broad brushing our solution as perfect is reckless. What we do know is that our solution is “Good for Members.”

  1. Simplicity – one benefit level without worrying about who is a covered provider
  2. Member Support – members get the direct number and direct email of a professional dedicated to helping them with both pre-service and post-service questions. This is really underestimated by even some of our happiest clients. It’s hard to believe how many relationships are formed and the comfort level members get from that consistent presence.
  3. Financial Protection – the better we are at reducing the cost of a claim, the less out-of-pocket expense hits that member.
    • Consider a claim in a PPO goes through at 225% of Medicare for a total of $3500 versus one we audit and gets paid at $2,275. If the plan has a $3,000 deductible, that member just saved $725 they possibly didn’t have. That could have been the difference between buying groceries or signing their kid up for their favorite sport.
    • Did you know some BUCAH contracts allow providers to charge coinsurance based on the billed charge amount as an incentive to join their network? Do that math and tell your employees you’re watching out for them.
  4. Price Stupid – the better we are at reducing the cost of a claim, typically the more money employers put in their employees’ paychecks. Reduced premiums and richer benefits are at the heart of our mission.

The next time you hear “bad for members,” please challenge that person to be more precise. There are too many people comfortable financially speaking for workers’ money. With our solution, you might see 10% of members have to change their doctor, or you might see a hand full of people get a balance bill that takes some time to resolve. BUT, 100% of plan participants will be much better off financially.