As a TPA, employer groups count on us to make their health benefits work. While that sounds easy enough, it can be anything but easy when ordinary working families face hospital bills they can’t handle.
One couple recently found themselves confronted by a hospital that rejected their coverage, demanding an advance payment of $9,000 for their child’s tonsillectomy, with a $10,000 balance due following the procedure. Because the employer has replaced their PPO network with Value Based Pricing (VBP), we were able to work with the parents, their regular pediatrician and ELAP Services to arrange for the procedure to be performed at a local, affiliated surgical center. Their total cost was less than $2,000 – a fraction of the original price.
While a great deal of work and cooperation were required to achieve this outcome, Value Based Pricing made it possible, by defining pricing limits in advance and encouraging dialogue between the patient, the provider and us as the TPA.
In a time when too many hardworking Americans are facing extraordinarily difficult healthcare decisions, helping employers and hospitals agree on pricing schedules for covered benefits may be the only way to keep quality healthcare within reach for small and mid-sized employers and the workers they depend on.
