Short answer: Unless the provider agreed to the plan’s price or a federal or state protection applies, the provider can bill the member for the difference. That balance-billing risk is why an RBP plan needs a balance-bill defense and member advocacy vendor in place from day one.
Reference-based pricing pays providers a benchmark amount, often a percentage of what Medicare would pay, instead of a network-negotiated rate. Whether a provider accepts that amount is a separate question; some RBP plans have direct agreements or a physician network, others have none.
Federal No Surprises Act protections still apply to self-funded plans: emergency services must be covered without prior authorization and regardless of network status, and certain nonemergency services by out-of-network providers at a participating facility are protected. Outside those situations, such as elective care at a facility with no agreement, a member can receive a balance bill.
Before placing RBP, examine the vendor’s balance-bill defense: who negotiates with the provider, whether the vendor pays settlements, legal defense of members, and indemnity terms. Also make sure the stop-loss policy recognizes the plan’s reference-based allowable amount and any settlement paid.