Medical Billing Defense for Self-Funded Health Plans and Reference-Based Pricing

Medical Billing Defense is the process of defending a self-funded health plan and its members against disputed, inflated, or escalated out-of-network bills. It's not claims auditing or repricing. It's what happens after a bill has been issued and a provider is pushing back. We manage the dispute, challenge the charges, and protect the plan and member through resolution.

Claims audits, bill reviews, and medical necessity reviews evaluate whether a claim was coded correctly, priced appropriately, or meets applicable coverage requirements. We handle what comes next: when the bill is disputed, a provider challenges the plan's payment, or a member is being pressured into paying. By the time aequum is involved, those review processes have typically already taken place.

Contact us immediately. The earlier we get involved, the more options we have. We intervene with the provider directly, dispute improper charges, and enforce defense to stop collections pressure. We also address any credit reporting threats at the same time.

Plan sponsors have a legal duty to act prudently and in the interest of their participants. Medical Billing Defense supports that responsibility by documenting dispute handling, responding to aggressive billing practices, protecting members from undue harm, and reducing exposure tied to unresolved claims.

Yes. RBP plans face consistent provider pushback and balance billing. We support the defense of RBP payment determinations, manage the resulting disputes, and reduce the disruption that comes with running a reference-based plan.

Reach out when a provider challenges a claim determination beyond the standard appeals process, when a member receives a balance bill or collections notice, when credit reporting issues arise, or when a high-dollar billing dispute requires legal advocacy. aequum is typically engaged when a matter moves beyond routine claims administration and into dispute resolution.

Balance billing is when a provider bills a patient for the difference between the allowed amount under the health plan and the provider's full charge. It happens most frequently with out-of-network providers, where providers aren't bound by a contracted rate. In reference-based pricing plans, providers push back on the plan's defined payment and attempt to collect the remainder directly from the member. It's a pressure tactic. The member, not knowing they may not legally owe the amount, often pays. That's exactly the situation aequum is built to interrupt.

Reference-based pricing plans pay providers a defined amount, typically a percentage above Medicare rates, rather than negotiating direct contracts with providers or entering into a network agreement. Providers who feel that the payment amount is too low may bill the member directly for the balance. This is one of the most common challenges associated with RBP plans, but it can be effectively managed with experienced advocacy and defense. aequum has worked with more than 900 health plans and handled over 13,000 claims, giving us extensive experience defending RBP payment determinations and resolving the balance billing disputes that follow.

Health plan compliance means operating your self-funded plan in accordance with ERISA, the No Surprises Act, and applicable federal regulations. When billing disputes arise and go unmanaged, they create compliance exposure: members may be harmed, fiduciary duties may go unmet, and the documentation regulators expect may be absent. Medical Billing Defense is part of how a plan sponsor demonstrates it's running the plan prudently.