RBP Vendor Capabilities
| Capability | Description | Importance |
|---|---|---|
| Claims repricing | Reprice claims to RBP rates and pay providers | Critical |
| Member advocacy | Dispute balance bills on behalf of members | Critical |
| Legal defense | Defend members and the plan against balance billing lawsuits | Critical |
| Provider relations | Negotiate with providers to accept RBP rates | High |
| Member communication | Prepare members for RBP and balance billing | High |
| Reporting | Report savings, balance billing rates, and outcomes | Medium |
Balance Billing Resolution Rate
The most important RBP vendor metric is the balance billing resolution rate — the percentage of balance bills that are resolved without member out-of-pocket cost. Top RBP vendors resolve 95%+ of balance bills without member cost. Vendors with lower resolution rates expose members to significant out-of-pocket costs and create employee relations problems.
Performance Guarantees
Pro Tip
Require performance guarantees from RBP vendors: (1) savings guarantee — minimum savings percentage vs. commercial network; (2) balance billing resolution guarantee — minimum percentage of balance bills resolved without member cost; and (3) member satisfaction guarantee — minimum member satisfaction score. Vendors who refuse performance guarantees are not confident in their program.