In this episode, Suzanne Spradley and Chase Cannon dig in to a trending topic, particularly for self-insured plans: reference-based pricing (RBP). Suzanne begins with a description of RPB, including an example to help illustrate how it works. Next, Suzanne explains the process and the pros and cons of RBP, which leads to a discussion on pricing and billing, including balance billing to unsuspecting plan participants. Suzanne outlines employer considerations when implementing an RBP design, including several issues with respect to the ACA and out-of-pocket maximums, and lessons learned from litigation relating to RBP strategies (including one case that made it to court with over $300K in claims at stake). The two close by discussing related ERISA fiduciary issues and administrative practicalities for employers to consider when adopting an RBP design.

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