RBP vs. Commercial Network Pricing
| Service | Commercial Network Rate | RBP Rate (150% Medicare) | Savings |
|---|---|---|---|
| Hospital inpatient (DRG) | 250% Medicare | 150% Medicare | 40% |
| Hospital outpatient | 300% Medicare | 150% Medicare | 50% |
| Ambulatory surgery | 250% Medicare | 150% Medicare | 40% |
| Imaging (MRI) | 400% Medicare | 150% Medicare | 63% |
| Lab services | 200% Medicare | 150% Medicare | 25% |
Balance Billing Risk
Balance billing is the primary risk of RBP. When a provider receives an RBP payment of 150% of Medicare and their billed charges are 300% of Medicare, they may bill the member for the difference. A robust RBP program includes: (1) member advocacy to dispute balance bills; (2) legal defense to fight balance billing lawsuits; and (3) member communication to prepare members for potential balance bills.
No Surprises Act and RBP
Compliance Note
The No Surprises Act (NSA) limits balance billing for emergency services and certain non-emergency services at in-network facilities. For services covered by the NSA, providers cannot balance bill members more than in-network cost-sharing. However, the NSA does not eliminate balance billing for all services — RBP plans must still manage balance billing for services not covered by the NSA.