Most health plans rely on a preferred provider organization (PPO) network. In this model, the PPO negotiates a contract with a facility and any claims incurred are paid based on that contract. In the VBP plan, facility claims are repriced based on a percentage of Medicare payment. This results in a lowered cost of care for everyone involved.
For procedures performed in a facility, the process begins during pre-certification. The plan requires you to gain preapproval for these procedures by calling the utilization review company at the number listed on your ID card.
At this time, the plan may provide an estimated payment amount to the facility. Once the procedure has been performed, the plan pays based on that estimate as well as any other charges incurred during the procedure, just like a normal plan.
Because these claims are paid outside of a network contract, there is a chance the provider will dispute the payment amount and potentially balance bill you. In these cases, you should contact Narus Health at the number on your ID card. Narus Health will work with the Patient Advocacy Center (PAC) to educate the provider on the plan payment and negotiate, if necessary, to settle the balance bill. You may be required to sign some documents allowing the PAC to advocate for you while it is resolving the bill. The PAC will keep you informed on the status of the efforts until an agreement is reached. Please note, the PAC process takes on average 60 days to complete.