In building products for public and private insurance exchanges, carriers emphasized lower-cost narrow-network products, accountable care organizations (ACOs) and other models. As expected, consumers generally chose coverage based on price, rather than on provider networks. But that won’t keep some enrollees from intentionally or accidentally seeking care from out-of-network providers. Given the dramatic growth of these new network models, and rapid reform efforts underway, health plan operators and self-funded employers will need to confront critical decisions regarding network design, fee schedule development and member engagement, or they could quickly find themselves with unexpected bills from out-of-network providers. Get solid strategies from Milliman and FAIR Health for navigating these decisions and determining out-of-network provider rates for ACOs, narrow networks and exchange-based products.
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.
For health plan operators, narrow or limited networks are proving to be a successful strategy for holding down coverage costs. But those arrangements also are beginning to cause clashes between carriers and providers, and health plans and self-insured plan sponsors must have a reliable and defensible strategy for reimbursing out-of-network providers. Innovative uses of benchmarking data will set organizations apart as the industry continues to evolve.
Hear from one of Milliman’s leading consulting actuaries, who specializes in provider contract review and benchmarking, and the president of FAIR Health, which has become a national clearinghouse for claims-based data. You’ll get answers to these and other questions:
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, health care 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, the managing editor of AIS's Inside Health Insurance Exchanges and The AIS Report on Blue Cross and Blue Shield Plans (Not affiliated with the Blue Cross and Blue Shield Association or its member companies.)
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