The Downside of Reference-Based Pricing: Balance Billing
Reference-based pricing (RBP) offers cost savings by reimbursing providers based on a predetermined rate. However, RBP has a major drawback that can lead to unexpected, often substantial, medical bills—balance billing.
What is Balance Billing?
Balance billing occurs when providers charge patients the difference between their fee and what insurance covers, often leading to surprise costs—especially with high-cost specialty medications and J-codes billed under the medical benefit. This creates financial stress and administrative burdens for employers, TPAs, and health plans that use RBP strategies.
RBP: Cost-Containment or Cost-Shifting?
At Golden Triangle Specialty Network (GTSN), we believe that you can’t call it “savings” unless both sides agree to the reimbursement rate. With our proactive approach, you can achieve more sustainable cost control and improve member satisfaction. GTSN protects everyone involved, including the patient.
A Future Without Balance Billing is Possible
Balance billing can create additional challenges, including increased claims disputes, higher administrative burdens, and dissatisfaction among plan members, making it harder to manage healthcare costs effectively.
At GTSN, we understand how hidden costs can hurt both employers and employees. Our expertise in managing specialty pharmacy and dialysis claims eliminates the possibility of surprise bills and claim disputes.
How GTSN Handles Balance Billing
We tackle the challenges of balance billing head-on:
- GTSN clients never experience balance billing issues.
- All discounts offered by GTSN come with the guarantee and security of provider sign-off.
Why Balance Billing is a Problem
Balance billing isn’t just an inconvenience—it can have serious financial and operational consequences for everyone involved, from patients to health plans and TPAs. Below are some key reasons why balance billing poses a significant challenge in healthcare:
Unexpected financial burden on patients: Patients often receive bills they didn’t anticipate, creating financial stress and dissatisfaction. This can damage trust in both the healthcare provider and the health plan.
Increased disputes between providers and payers: When providers and payers aren’t aligned on pricing, it leads to costly and time-consuming disputes that TPAs and health plans must manage.
Administrative complexity: Balance billing complicates claims processing, resulting in more administrative work, which increases operational costs.
Lack of pricing transparency: Specialty medications and J-code services are often billed under the medical benefit through PPO networks, where pricing isn’t as clear or predictable. This makes it difficult for payers to anticipate and control costs.
Negative impact on employee satisfaction: For self-funded employers, balance billing can create employee dissatisfaction, as workers may feel blindsided by high medical bills they thought were covered by their insurance.
How GTSN Can Help
GTSN specializes in reducing the financial strain and administrative headaches caused by balance billing, particularly for specialty medications and J-codes. Our comprehensive approach helps ensure that claims are billed correctly under the medical benefit, preventing the costly surprises of balance billing.
How We Make a Difference
Expertise in specialty Rx (J-codes) and dialysis: GTSN focuses on dialysis and high-cost treatments commonly billed as J-codes, where balance billing is more likely to occur.
Proactive cost management with provider signoff: GTSN works directly with providers to ensure transparency in pricing and correct billing practices from the start. This proactive approach eliminates disputes and cuts down on administrative back-and-forth. We boast a 100% guarantee on provider sign-off.
Protecting our clients: By managing specialty medication claims effectively and responsibly, GTSN eliminates the risk of balance billing, which eases the administrative burden on TPAs and health plans. This results in smoother claims processing, happier plan members, and better overall cost control.
With GTSN’s targeted expertise and proactive approach, employers, TPAs, and health plans can all benefit from reduced costs, fewer disputes, and more satisfied members.
To learn more about how GTSN can help your organization avoid balance billing issues, contact Hy Byrd, COO of GTSN, at 615.712.6289, or explore more of our website.