Risky business for dialysis services.
When self-insured health plans and their third-party administrators pay an artificially low out-of-network rate for dialysis services, they could be liable for the difference between that rate and the reimbursement level provided for by their health plan. Paying a rate that the repricers advised them to pay does not relieve self-insured health plans and third-party administrators of that obligation; only where the repricer has legitimately secured a negotiated contract rate is a lower payment justified. [Editor's note: The term "repricer" has no universally-accepted or formal definition, but it will be used here to describe those companies formed to act as middlemen between health care payers-like self-insured employer plans and TPAs working on behalf of such plans-and health care providers.] Failing to adhere to this will result in lawsuits against self-insured health plans and third-party administrators where they will be forced to defend the repricers' recommended payment amounts, while the repricers try to get themselves dismissed. A better option for plan holders and third-party administrators would be to negotiate directly with the dialysis providers and agree upon a mutually acceptable rate.
Schohl
Joseph
J
GeneralCounselWest, Westlake Village, Calif., USA.
D003363:Cost Control; D003362:Cost-Benefit Analysis; D019461:Employee Retirement Income Security Act; D006264:Health Benefit Plans, Employee / Q000458:organization & administration; D006801:Humans; D019458:Insurance Coverage / Q000458:organization & administration*; D007349:Insurance, Health, Reimbursement / Q000191:economics / Q000331:legislation & jurisprudence; D016365:Liability, Legal; D008389:Marketing of Health Services; D006435:Renal Dialysis / Q000191:economics*; D012308:Risk Management / Q000458:organization & administration*; D014481:United States