Transparent Open Networks

Bundled Payments

Traditional fee-for-services models reimburse providers based on the quantity of services and can encourage over-utilization. Bundled payment for a specific treatment or condition allows employers to reimburse providers for all the services needed across the entire treatment or condition.

You trade endless, confusing, itemized bills for just one bill covering the hospital, surgeon, anesthesia, equipment, etc. For treatment across a specific condition there is just one bill for all physician visits, diagnostics, and care management.

Shared Risk

Fee for service payments can encourage overutilization and provide reimbursement based on quantity alone. Shared risk models encourage providers to account for the cost of services provided and the outcomes associated with services rendered either for a specific treatment or condition. Shared risk is most commonly addressed through a structure of global periods. Medicare has long required providers to share risk under 3 different global periods; Zero Day Post-operative Pare, 10-day Post-operative period and 90-Day Post-operative period. Medicare isn’t going to pay for mistakes, complications and re-admissions. Transparent open networks bring that practice to the private sector.

Efficient Administration

Typical claims administration is filled with inefficiencies: slow payment cycles, prior authorization, network requirements, complicated payment models, employee cost sharing, etc. For a Transparent Open Network to function, employers must make it easy for employees to access care, offer quick pay to providers (typically five days or less), eliminate barriers like copays and deductibles, and often remove oversight requirements like prior authorization. It’s important to remember that the goal of this model is to simultaneously lower employer costs, reduce costs and eliminate hassles for providers, and provide a true benefit to employees and members.

Employee Education

Models that encourage the use of specific providers for specific treatments are often a new idea for employees and their families. They need to understand that TMM is not like HMO models, which were often associated with denied care, long wait times, and poor customer service. The message needs to be simple, clear, intriguing, and just one sentence like this: Don’t forget, if you need medical care, we have a group of the highest-quality providers you can see, and choosing this won’t cost you anything out of pocket.

Ease of Use

Health care has always been confusing, frustrating, and very often scary. A Transparent Open Network should be effortless. Consider offering concierge-style customer service, which gives your employees easy access to the humans and resources they need, including hassle-free appointment scheduling, medical records transfer, and both web and mobile access. These services can also create comfort for your employees around sensitive health issues they don’t want to discuss with you or your internal benefits manager.