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Webinar Details

  • Pub Code: C3R22-11WEB
  • Speakers
    • Robin Gelburd
    • Robert Parke

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Out-of-Network Rates for New Plan Models: How FAIR Health and Other Data Sources Are Being Used for ACOs, Exchanges and Narrow Networks

May 16, 2013 Webinar - Listen On-Demand or Get a CD!

Private and public exchanges, accountable care organizations (ACOs) and narrow-network insurance products are about to dramatically reshape the health insurance marketplace. For health insurers and self-funded employers, the ability to engage consumers and accurately benchmark provider rates will be essential. While millions of uninsured people are expected to gain coverage beginning in 2014, the health of the overall risk pool, limits on age-ratings bands and participation fees for exchanges will pressure premiums. But consumers are expected to choose coverage based on price, rather than on provider networks or brand recognition. In response, carriers will emphasize narrow-network products, cost-saving ACOs and other models. And calculating out-of-network rates will be critical. Benchmark data also are invaluable when communicating the value of insurance exchanges to consumers who have limited or no experience with health insurance. Innovative uses of data will set organizations apart as the industry continues to evolve. Hear a highly informative presentation of how different data sources may be used to set out-of-network rates in exchanges, ACOs and narrow networks.

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The On-Demand recording will be available immediately upon purchase* as a link within a PDF file of the accompanying written materials. CDs and printed materials are shipped via USPS.

Sponsored by Atlantic Information Services, Inc., publisher of Health Plan Week, Inside Health Insurance Exchanges, Drug Benefit News and AIS’s Health Reform Week

It’s been nearly five years since New York’s attorney general investigated the state’s out-of-network reimbursement system and concluded it was flawed. UnitedHealth Group and 10 other insurers contributed nearly $100 million to a 2009 settlement, a portion of which was used to launch FAIR Health, Inc., a not-for-profit entity that has become a national clearinghouse for claims-based data.

Since then, the health insurance marketplace has undergone its greatest transformation since HMOs were introduced 40 years ago, with ACOs, narrow networks and insurance exchanges redrawing the national landscape.

Hear all the specifics about how FAIR Health and other data alternatives can be used for ACOs, insurance exchanges and narrow-network products. You’ll hear directly from FAIR Health’s president and a leading consulting actuary who specializes in provider contract review and benchmarking. You’ll get answers to these and other questions:

  • Why do health plans need a sound and defensible source of benchmark data?
  • How can benchmark data be repurposed to help build consumer education and cost and transparency tools?
  • How should health plans use UCR rates to price exchange-based products?
  • Why are benchmark data important for exchange products?
  • What models exist today for setting out-of-network rates? What are the relative advantages and disadvantages of each?
  • How can chronic disease and treatment cost profiles be used to promote enrollment and informed use of benefits on the exchange?
  • What are the pros and cons of basing out-of-network rates on a percentage of Medicare?
  • How can cost and utilization trending over time and geography help organizations manage provider contracting and benefit design?
  • How should benchmarking data be used to determine charges under value-based payment mechanisms such as ACOs?


ROBIN GELBURD is president of FAIR Health, Inc., a national, independent nonprofit with the mission of bringing fairness and transparency to health care costs and insurance reimbursement. FAIR Health uses its database of more than 15 billion billed medical and dental procedures to power a free website that enables consumers to estimate and plan their health care expenditures. In addition to its consumer offerings, FAIR Health licenses data to insurance plans, third party administrators, brokers, benefits advisors, government agencies, healthcare providers, and researchers. Ms. Gelburd joined the organization when it was founded in October 2009. Before she was recruited to FAIR Health, Ms. Gelburd served for eight years as General Counsel of a foundation dedicated to the promotion of biomedical research. Ms. Gelburd also served as Chairperson of a statewide coalition that had as its mission the promotion of state funding and support for stem cell research. Prior to her tenure as General Counsel, Ms. Gelburd was a health law partner at Kalkines, Arky, Zall & Bernstein (now Manatt, Phelps & Phillips LLP). During her 10 years at that firm, she represented a wide array of health care-based clients on a variety of strategic, regulatory, policy, governance, business, and contractual matters. Previously, Ms. Gelburd worked as a litigation and corporate associate at the international law firm Morrison & Foerster. She began her legal career as a federal appellate law clerk to the Honorable Francis D. Murnaghan, Jr. from the Court of Appeals, 4th Circuit.

ROBERT PARKE is a principal and consulting actuary in the New York City office of Milliman, where he provides actuarial and consulting services to a broad range of clients, including Blue Cross and Blue Shield plans, HMOs, commercial insurers, government agencies and health care providers and vendors. Mr. Parke’s work includes rate development and review, provider contract review and benchmarking, evaluations of pay-for-performance and disease-management programs and the development of risk-sharing and reimbursement arrangements for physician groups and other integrated delivery systems. Prior to joining Milliman in 1995, Mr. Parke worked at Tillinghast, a Towers Perrin Company. In addition, he has worked extensively in health insurance in the United Kingdom and South Africa.

Moderator: Steve Davis, managing editor of AIS's Health Plan Week and Inside Health Insurance Exchanges

Designed Especially For

  • Health plans
    • CEOs, COOs and CFOs
    • Provider relations directors
    • Actuaries
    • Attorneys
    • Product developers
    • Market research analysts
    • Government and public affairs directors
  • Self-insured employers
    • CFOs
    • Human resources executives
  • Health systems and other provider organizations
    • Administrators
    • Finance officers
    • Managed care contracting directors
  • Financial analysts, including securities and credit analysts
  • Consultants
  • Insurance Brokers

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Out-of-Network Rates for New Plan Models: How FAIR Health and Other Data Sources Are Being Used for ACOs, Exchanges and Narrow Networks

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