Shift Shapers Podcast

07 Dec 2020

Ep #339: Paying the Claim After Paying the Claim – with Jordan Hersh

David Saltzman 0 Comments

This week’s episode features a conversation with Jordan Hersh, Vice President, Enterprise Solutions at Vālenz. Renegotiating out-of-network claims can provide cost savings to members. On the plans side, Jordan also explains how offering discounts can help ensure timely payments. If insurers communicate the benefits of staying in-network and offering incentives, this can avoid confusion with the EOB and arm members with the knowledge of how post-claims adjudication works.

What You’ll Learn From This Episode:

  • 02:01 Reference-based pricing: Finding the right fit for self-funded plans
  • 04:26 Defining narrow networks and high-performance networks
  • 08:31 Saving money: Renegotiating out-of-network claims and offering discounts
  • 13:42 Communicating costs to members and incentivizing in-network claims
  • 15:44 Transparency in out-of-network claims
  • 18:42 How much savings can a self-funded plan expect?


05:10 “Readmission rates, complication rates, mortality rates, we’re taking that into account and making sure that when people do people stay in-network or go to the panel of those high-performance network partners, they’re getting top tier coverage.”

08:46 “Depending on the primary PPO network regardless of broad network or network of concise nature, there’s going to be out-of-network medical claims. And that can cost self-funded plans a lot of money if it’s not managed correctly.”

09:45 “Some plans we’ve seen pay out-of-network claims at full bill charges, some take a usual customary approach. Having a much more direct and aggressive approach can really be a game-changer for self-funded plans and materially impact the bottom line.”

10:38 “So being able to achieve a discount, that can also assure them that they’re going to be paid and have a little bit more clarity on how the member responsibly can be split up. Oftentimes we see self-funded plans offering some type of incentive.”

19:22 “So a plan with a medical spend with a million dollars, implementing these types of tools into the right education training to the members, could reduce their overall medical spend by about 25%.”


Download a copy of the “Nationwide Evaluation of Health Care Prices Paid by Private Health Plans: Findings from Round 3 of an Employer-Led Transparency Initiative” by clicking this link.

Listen to the Full Interview:

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