Employers sponsoring and fiduciaries administering health plans that rely upon Medicare-based or other reference-based pricing (“RBP”) methodologies with or without narrow network design features to project and control out-of-network health plan costs likely are incurring higher than expected out-of-network costs, as well as avoidable NSA enforcement and noncompliance liabilities. To mitigate these exposures and avoid unknowingly continuing these exposures into the 2027 plan year sponsors and fiduciaries should verify their NSA compliance, compare their actual out-of-network expenses against their original assumptions, and ensure timely and effective administration of out-of-network claims to mitigate NSA and other liabilities before year-end.

Recently published data suggests most self-funded employer plans RBP formulas bear little relationship to the amounts those plans ultimately pay when a claim falls within the No Surprises Act (“NSA”) and proceeds through negotiation or federal Independent Dispute Resolution (IDR).

The disparity between predictions and ultimate payouts increasingly leaves many employers with unexpectedly higher health plan costs, often made worse by delayed payout of NSA-required payments falls outside stop-loss coverage timelines, added administration and enforcement costs and penalties.

For employers relying on RBP assumptions to establish plan funding, premiums, employee contributions, stop-loss attachment points, reserves, or expected out-of-network claim costs, this disparity can translate into material and potentially significantly lighter than projected plan liabilities. The same data also call for closer scrutiny of the narrow-network health plan designs often touted as reducing in-network unit prices, as these narrow networks can increase the frequency or severity of out-of-network and NSA-protected claims when participants cannot obtain needed care from participating providers.

New Data Highlight the Potential RBP/NSA Gap

Reference-based pricing remains an important cost-management strategy for many self-funded employer health plans. Rather than paying providers based upon a negotiated percentage discount from billed charges, a health plan relying a RBP strategy to price out of network claims commonly establishes payment by reference to Medicare reimbursement, provider cost, or another external benchmark.

A significant Health Affairs Scholar study examined a reference-based pricing program covering approximately 300,000 lives nationwide for self-funded employers. The program generally paid hospitals the greater of cost plus 12% or Medicare plus 20%, producing payments averaging approximately 140% of Medicare. Analysis of 2024 claims found average payments of approximately 122% of Medicare for inpatient facility services and 149% for outpatient facility services. Replying on this data without considering the NSA mandates, researchers estimated referenced based savings of approximately $417 million, or 56.5% compared with ordinary commercial prices. When the NSA is considered, however, these projections substantially underestimate plan costs.

NSA Arbitration Outcomes Can Be Multiples of Medicare-Based RBP Amounts

The NSA protects participants from certain surprise bills for out-of-network emergency services, certain non-emergency services furnished by out-of-network providers at participating facilities, and covered air ambulance services. When the plan and provider cannot agree upon payment for claims governed by the federal NSA process, the dispute can proceed to federal IDR.

Federal IDR is a baseball-style final-offer arbitration process in which each side submits an offer and the certified IDR entity selects one of the two offers. Brookings overview of federal IDR.

Brookings analysis of CMS data found average IDR prices during the second half of 2023 of approximately 400% of Medicare for emergency professional services and approximately 660% of Medicare for imaging services. Brookings IDR outcome analysis.

More recent analysis of CMS’s 2024 federal IDR data found average imaging IDR pricing approaching approximately 767% of Medicare. Brookings NSA Arbitration Databook.

Thus, a plan assuming an out-of-network claim will cost approximately 140% of Medicare under its RBP methodology could face an IDR award of roughly 400% of Medicare for some emergency services – nearly 2.9 times the RBP assumption – or roughly 767% of Medicare for certain imaging claims – approximately 5.5 times the RBP assumption.

These figures do not establish a single national RBP rate or guarantee any particular NSA award. But they demonstrate a risk that employers using RBP methodologies should not ignore: the amount used to price an out-of-network liability for plan design and budgeting purposes can be substantially lower than the ultimate amount payable if the claim becomes subject to NSA negotiation and IDR.

The Latest CMS Data Show This Is No Longer a Marginal Risk

CMS reported in May 2026 that more than 5 million disputes had been initiated through the federal IDR system since it began operating in April 2022. CMS May 2026 release.

During July 1 through December 31, 2025, certified IDR entities rendered payment determinations in 1,145,039 disputes. Emergency department services represented 52% of those determinations, radiology another 15%, providers prevailed in about 85% of payment determinations, and the prevailing offer exceeded the QPA in about 87% of determinations. Providers also prevailed in about 90% of default determinations. CMS Federal IDR Supplemental Background, 2025 Q3-Q4.

RBP Plan Sponsors Should Distinguish Three Different Numbers

Plan sponsors reviewing this exposure should avoid treating the RBP amount, the Qualifying Payment Amount (“QPA”), and the ultimate NSA payment amount as interchangeable.

The RBP amount is established under the particular terms of the plan or payment methodology and may, for example, approximate 120%, 140%, 150%, 200%, or another percentage of Medicare.

The QPA generally reflects the plan or issuer’s median contracted rate for the same or similar item or service, calculated under the NSA methodology. CMS maintains detailed guidance regarding QPA calculation and federal IDR responsibilities. CMS Plans and Issuers Requirements and Resources.

The ultimate NSA payment amount may result from agreement during negotiation or from the offer selected by a certified IDR entity. Since data shows these NSA payment amounts tend to run significantly higher than the RBPs used to predict plan costs, forecasting a plan’s liability initially at its RBP amount sets up plans and their sponsors for unexpected financial exposure.

Narrow Networks May Create an NSA Cost-Control Paradox

The emerging NSA payment data also should cause employers to question another increasingly popular cost-control strategy: aggressively narrowing provider networks.

Narrow networks traditionally are designed to lower health plan costs by excluding higher-cost providers, concentrating volume among selected providers, strengthening negotiating leverage, and steering participants toward lower-cost facilities and physicians.

Published research confirms that narrow networks can lower premiums and spending when care actually obtained within the network. One Health Affairs study found that Marketplace plans with both narrow physician and hospital networks had premiums approximately 16% lower than comparable broad-network plans. Health Affairs study of network breadth and premiums

Another study found that narrow-network plans reduced utilization and spending in an employer setting in part by selecting lower-cost providers. Journal of Health Economics study

KFF’s 2025 Employer Health Benefits Survey reported that about 9% of employers offering health benefits reported offering a plan characterized as a narrow-network plan, with the strategy more common among very large employers. KFF 2025 Employer Health Benefits Survey

Fewer Network Providers Can Mean More Opportunities for Out-of-Network Care

By definition, a narrower network reduces the number of physicians, hospitals, and other providers available to participants at negotiated in-network prices. When excluded providers are geographically concentrated, specialty providers are scarce, or the nearest appropriate hospital or physician does not participate, the probability that a participant will receive care outside the network logically increases.

A Health Affairs study of California provider networks found that Marketplace networks contained only slightly more than half as many providers as commercial networks and that network design sometimes created ‘artificial local provider deserts’ in which otherwise available physicians were effectively unavailable because they were excluded from the network. Health Affairs study of network adequacy and local provider access

A systematic review of narrow and tiered networks concluded that these arrangements generally reduce health care costs, while evidence regarding access and quality remains more limited and warrants further study. Systematic review of narrow and tiered provider networks.

Accordingly, employers should not assume that shrinking a network necessarily reduces every category of plan cost. A network can produce lower negotiated prices for claims that remain in-network while simultaneously increasing the frequency with which participants encounter providers outside the network.

Emergency and Hospital Care Demonstrate the Exposure

Before the NSA, a JAMA Internal Medicine study examining approximately 5.5 million inpatient admissions and 13.6 million emergency department visits found that by 2016 an out-of-network bill was associated with approximately 42.8% of emergency department visits and 42.0% of inpatient admissions at in-network hospitals in the study population. JAMA Internal Medicine study.

Research involving employer-sponsored insurance likewise found meaningful out-of-network spending exposure, particularly for hospitalists, pathology, laboratory, and other facility-based services. Health Affairs study of out-of-network spending in employer-sponsored insurance.

A 2024 Health Affairs Scholar study using employer-sponsored commercial claims found that approximately 34% of ICU hospitalizations contained out-of-network services, and more than half of those mixed-network hospitalizations included out-of-network services delivered within the ICU itself. Health Affairs Scholar ICU surprise-billing study.

These findings matter because patients requiring emergency, intensive-care, anesthesia, radiology, pathology, and similar services frequently have little practical ability to select every professional involved in their care. The NSA protects patients from many resulting balance bills, but it does not eliminate the economic dispute between the out-of-network provider and the plan. It moves that dispute to negotiation and, where applicable, IDR.

The NSA Can Convert a Network-Access Problem Into a Plan Liability

The latest CMS data show why this can matter. During the second half of 2025, emergency department services accounted for 52% of federal IDR determinations and radiology another 15%; providers prevailed in about 85% of determinations, and the prevailing offer exceeded the QPA in about 87% of cases. CMS Federal IDR Supplemental Background.

Separate analysis of 2023 emergency-medicine IDR data found providers won approximately 86% of disputes involving a commonly disputed moderate-to-severe emergency visit, with the mean selected payment approximately 2.7 times the QPA. Health Affairs Scholar emergency-services IDR study.

Those outcomes create a potential cost-control paradox. An employer may narrow its network to negotiate a lower contracted rate or eliminate a provider demanding what the employer considers an excessive in-network price. But if participants nevertheless require services from that provider – particularly in an emergency or other NSA-protected setting – the employer may lose much of the financial advantage it expected to achieve from excluding that provider.

In the extreme case, a network strategy intended to avoid paying an allegedly excessive negotiated rate could expose the plan instead to an NSA IDR award materially greater than the amount at which the provider might have participated in-network. The data do not yet establish that this occurs systematically across employer plans, but the possibility warrants plan-specific analysis. However, these costs unquestioningly increase if a RBP health plan fails to timely and effectively use the NSA procedures to mitigate its NSA risks.

Aggressive Network Negotiations May Have a Second-Order Cost

Selective contracting is one mechanism through which narrow networks reduce costs. One economic analysis found that lower negotiated prices accounted for about 15% of narrow-network savings, while steering patients away from higher-cost hospitals accounted for another 18%. Health Economics analysis of narrow-network savings

If a plan or network administrator presses reimbursement rates below the level at which a sufficient number of physicians and facilities are willing to remain in-network, however, the network may become narrower not merely because inefficient providers were intentionally excluded, but because providers participants actually need are unwilling to contract at the offered rate.

Economic research has shown that out-of-network options historically influenced emergency physician contracting behavior and reimbursement. In one study, regulatory changes weakening emergency physicians’ out-of-network bargaining position reduced out-of-network billing by 34% and reduced in-network emergency physician payments by about 9%. NBER study of out-of-network emergency physician bargaining.

That research does not prove that aggressive payer negotiations presently are causing NSA arbitration volume. It does demonstrate that network participation, negotiated rates, and the economic value of remaining out-of-network are interconnected. The NSA therefore should be incorporated into network contracting analysis rather than treated as a separate claims-processing issue.

Recent Federal Data Provide an Important Counterpoint

A February 2026 GAO report found that in-network emergency-medicine physician participation declined before implementation of the NSA but rebounded beginning in 2022, suggesting that the NSA may have strengthened incentives for some providers to participate in networks. GAO report on provider participation before and after the NSA.

A February 2026 HHS Assistant Secretary for Planning and Evaluation report found that, compared with 2021, the prevalence of out-of-network bills declined approximately 15% for emergency services and 11% for covered non-emergency services at in-network facilities in 2022, the first year of NSA implementation. HHS ASPE No Surprises Act report

These findings are important because they show that the NSA itself may reduce some out-of-network utilization and improve incentives to contract. They do not eliminate the concern for narrow-network employers. Even if the frequency of out-of-network encounters falls, the financial severity of the remaining disputes can still be material when IDR awards substantially exceed RBP assumptions, the QPA, or expected negotiated rates. Network design along with health plan’s RBP assumptions and preparedness and effectiveness in using the NSA negotiation and IDR process therefore should be evaluated by considering both frequency and severity.

Sponsors Should Revisit RBP Funding Assumptions and Network Breadth

Employers and fiduciaries sponsoring RBP plans should consider incorporating an NSA risk factor into plan budgeting and forecasting rather than assuming that all out-of-network claims ultimately will be payable at the plan’s ordinary RBP amount. They also should test whether the breadth and geographic distribution of the network are contributing to avoidable out-of-network exposure.

• the number and dollar amount of NSA-eligible claims;
• the specialties and facilities generating the largest number of disputes;
• initial RBP allowed amounts and applicable QPAs;
• provider demands, negotiated settlements, and IDR outcomes;
• the number of disputes attributable to providers excluded during network negotiations;
• participant travel distances and practical access to in-network emergency, hospital, and specialty care;
• administrative and IDR fees; and
• recoveries actually obtained under stop-loss coverage.

Plan actuaries, consultants, TPAs, network administrators, and stop-loss advisers should be asked expressly how NSA liabilities are reflected in projections and whether historical claims data include ultimate NSA settlement or arbitration amounts rather than merely original RBP adjudication amounts.

Conduct a Year-End NSA Liability Review Now

The approaching end of the year creates an immediate administrative concern. Employer plan sponsors should identify existing claims that could produce additional NSA liability before those claims fall through administrative cracks during year-end processing.

• claims subject to an open negotiation period;
• claims already submitted to federal or applicable state IDR;
• claims awaiting an eligibility determination or required submission;
• claims awaiting a determination;
• provider demands or correspondence that have not been appropriately escalated;
• IDR determinations not yet fully paid;
• claims potentially payable under stop-loss coverage but not yet submitted; and
• claims approaching contractual notice, submission, proof-of-loss, run-out, or reimbursement deadlines under the stop-loss policy.

Don’t Let Stop-Loss Reimbursement Fall Through the Cracks

The difference between an initial RBP allowance and a later NSA settlement or IDR award can create a stop-loss administration problem. A plan that initially adjudicates a claim below its specific attachment point may later incur a substantial additional NSA liability that moves the claim above the attachment point. Whether and when that additional amount is reimbursable depends on the actual stop-loss contract.

Particular attention should be paid to provisions defining when a claim is incurred, paid, or otherwise eligible for reimbursement; run-in and run-out provisions; claims submission deadlines; proof-of-loss requirements; exclusions; specific and aggregate attachment points; terminal liability provisions; and notice requirements for potentially large claims.

An employer should not assume that its medical TPA, RBP vendor, IDR administrator, network administrator, and stop-loss carrier are communicating effectively with one another. The employer and appropriate plan fiduciaries should verify it.

Plan Sponsors and Fiduciaries Should Examine Their NSA Compliance and Administration Strategy

Compliance with the NSA is mandatory. Meanwhile, fiduciaries’ duties to prudently administer the plan includes responsibility to ensure the prudent administration of the plan in accordance with the NSA’s negotiation and IDR procedures and payment of resulting benefit liabilities. Mishandling of these responsibilities both can increase plan costs and liabilities and create fiduciary liability for responsible plan fiduciaries. Since absent special negotiated provisions, most plan administrative services agreements designate the sponsoring employer or its leaders the named fiduciary, this means most current plan administration arrangements leave the plan sponsor and its leaders responsible for plan matters with significant cost and liability exposure.

To fulfill these duties and mitigate exposures, employers sponsoring group health plans and plan fiduciaries should act quickly to prudently audit and address their plan’s current and future fulfillment of NSA responsibilities and resulting costs and expenses.

CMS maintains a federal IDR checklist and related resources specifically for plans and issuers. CMS NSA resources for plans and issuers.

The Departments also finalized new federal IDR operational rules in May 2026 designed to improve communications, eligibility determinations, disclosures, and IDR administration. CMS Federal IDR Operations Final Rule fact sheet

Employers and fiduciaries should work with experienced legal counsel to evaluate and confirm that administrators have implemented and prudently administered plans in accordance with current requirements and prepared to administer the plan effectively with the evolving rules going forward.

This evaluation generally should include documented prudent evaluation of historical compliance as well as evaluation of the advisability of tightening contractual and operational responsibility among the plan’s third party administrator, RBP administrator, network administrator, NSA negotiation vendor, IDR administrator, legal counsel, and stop-loss carrier or managing general underwriter.

Recognizing the ERISA’s fiduciary responsibility requirement that these service providers be prudently selected and paid no more than reasonable compensation, these evaluations also should include and document prudent evaluation and findings of these matters with respect to these NSA administrative arrangements.

Strategic Negotiation May Be Worth Real Money

The potential difference between an RBP amount and an adverse IDR award changes the economics of negotiation. A plan ordinarily expecting to pay 140% of Medicare should not necessarily approach an NSA demand in the same manner as an ordinary balance-billing dispute. Competent pre-IDR analysis should evaluate the QPA, applicable Medicare reimbursement, relevant contracted rates, prior payment history, provider market characteristics, complexity and acuity of the service, permissible statutory considerations, prior negotiations, the provider’s likely IDR position, and the economic value of a defensible negotiated resolution compared with proceeding to IDR.

The objective is not indiscriminate settlement. It is prudent efforts to reach informed settlement and where settlement can’t be prudently reached, a informed arbitration strategy.

Fiduciary Oversight Matters

For ERISA-covered self-funded plans, these concerns also implicate fiduciary administration. An employer or fiduciary need not personally process every NSA dispute, but prudent delegation of those functions to a TPA or specialized vendor requires thoughtful vendor selection, monitoring, contracting, and oversight.

• avoiding preventable IDR disputes;
• identifying appropriate settlement opportunities;
• developing defensible IDR submissions;
• meeting every deadline and avoiding defaults;
• tracking final payment obligations;
• coordinating stop-loss submissions; and
• reporting material NSA exposure to the employer and fiduciaries.

The Lowest Negotiated Rate Is Not Necessarily the Lowest Total Cost

The object of health plan network contracting should be the lowest prudent total cost of providing promised benefits – not simply obtaining the lowest possible negotiated unit price or the narrowest possible network. An employer may negotiate a reduction in a physician’s proposed contracted rate and regard exclusion of the physician as a success when the provider refuses. That conclusion may be wrong if removing the provider forces participants into NSA-protected out-of-network care that ultimately costs the plan substantially more.

Employers should require administrators, brokers and consultants to accept accountability in their contracts, acknowledge fiduciary status when exercising discretion, and measure network prices, utilization, out-of-network incidence, NSA settlements, IDR awards, administrative costs, and stop-loss recoveries together. The appropriate metric is total plan cost within the bounds of prudent administration of the plan in accordance with the NSA and other laws, not merely network discount.

Action Steps Before Year-End

Considering these and other responsibilities and risks, plan sponsors and fiduciaries should take several actions before year end to manage these responsibilities and risks. Some key steps include:

• Plan sponsors and fiduciaries should evaluate the plan’s NSA compliance and RBP assumptions. Compare the RBP percentage used for plan pricing against actual NSA settlements and IDR outcomes and evaluate an appropriate reserve or contingency assumption.
• Plan sponsors should critically assess network breadth. Identify geographic and specialty gaps, recurring out-of-network providers, and whether excluded providers are generating disproportionately expensive NSA claims.
• Plan fiduciaries should prudently audit compliance and reconcile outstanding NSA claims. Obtain a claim-level inventory of every pending negotiation, state or federal IDR dispute, unresolved provider payment challenge, and unpaid IDR determination. Also assess paid out-of-network claims for potential outstanding NSA or other liability.
• Identify the financial delta. For each significant claim, compare the original RBP allowance, QPA, provider demand, current settlement exposure, and reasonably possible IDR exposure.
• Review high-risk claims strategically. Determine whether well-supported negotiations before IDR could reduce exposure and whether pending arbitration submissions contain the factual and legal information needed to defend the plan’s position.
• Calendar every NSA deadline. Avoid preventable defaults and missed response dates.
• Audit past NSA claims. If the audit of previous processed put-of-network claims indicates higher than necessary liability due to mishandling of the NSA negotiation or IDR processes, consult with legal counsel regarding prudent actions, if any, as may be warranted to address those missteps and to prevent their reoccurrence.
• Coordinate with stop-loss coverage now. Identify claims that have exceeded or could approach attachment points and determine applicable notice, proof-of-loss, reimbursement, and run-out deadlines.
• Audit TPA and vendor performance. Determine who is responsible for identifying NSA claims, negotiating them, initiating or defending IDR, approving offers, paying awards, reporting outcomes, and pursuing stop-loss reimbursement.
• Evaluate 2027 budgeting. Do not assume the plan’s RBP percentage represents the maximum probable liability for NSA-eligible out-of-network services.
• Preserve and analyze the data. Require claim-level records that allow the employer to measure RBP allowance versus QPA versus negotiated amount versus IDR award versus stop-loss recovery, together with the provider’s network status and geographic availability.

Bottom Line

Reference-based pricing and narrow networks both can be powerful tools for controlling employer health plan costs. Published research supports that conclusion. But the No Surprises Act has changed the financial environment in which those strategies operate.

A plan that ordinarily expects to pay approximately 120% to 200% of Medicare for an out-of-network service may face dramatically different economics when the claim is protected by the NSA and proceeds through negotiation or IDR. At the same time, a network strategy that lowers in-network unit prices may create greater out-of-network exposure if it leaves participants without practical access to needed providers.

No published study identified to date establishes that narrow networks have caused aggregate employer NSA costs to exceed the savings those networks generate. The more relevant question for an individual plan is whether its particular combination of network design, reference-based pricing, NSA claims experience, and stop-loss coverage is actually producing the savings assumed when the arrangement was designed.

With CMS reporting more than 1.1 million federal IDR determinations during the final six months of 2025 alone, employers should evaluate that question using their own claims data before renewing network strategies, establishing 2027 budgets, and allowing unresolved 2026 NSA and stop-loss liabilities to disappear into year-end claims administration.

The prudent strategy is not necessarily broader networks, nor necessarily narrower networks. It is a deliberately designed network broad enough to provide meaningful access to needed care, negotiated at defensible prices, coupled with reference-based pricing and NSA administration that is legally compliance and prudently administered to minimize the plan’s total expected cost rather than merely its apparent in-network unit prices.

For Help or More Information

The author of this update, Cynthia Marcotte Stamer has decades of experience advising and assisting health industry clients to design, audit, and defend their organizations and practices including conducting audits and investigations, designing and updating compliance and risk management programs, responding to government investigations, conducting transaction, governance, and other due diligence, and assisting with other legal and operational compliance and risk management and legislative and regulatory affairs. She is available to assist your organization in assessing the impact of these developments and navigating the compliance and strategic steps that follow. For more information about these or other health care, managed care and other health benefits, or other health industry laws or concerns, contact Ms. Stamer via e-mail or via telephone at (214) 452 -8297.

About the Author

Cynthia Marcotte Stamer is an American College of Employee Benefits Counsel and a Martindale-Hubble “AV-Preeminent” (Top 1%) attorney and advisor board certified in labor and employment law by the Texas Board of Legal Specialization peer peer celebrated as “Top Rated Lawyer” and “LEGAL LEADER™ “Top Rated Lawyer” and “Best Lawyer” for her work in ERISA & Employee Benefits Law, Health Care Law, Labor and Employment Law, and Business and Commercial Law.

Nationally recognised for her decades of leading edge health and other employee benefits and insurance, compensation, human resources and other management work, public policy leadership and advocacy, coaching, teachings, and publications, Ms. Stamer is well known for her decades of pragmatic, leading edge work, scholarship and thought leadership on health benefit and other health and managed care, privacy and data security and other employee benefit, insurance, and health industry legal, public policy and operational concerns. 

Ms. Stamer’s work throughout her career has focused heavily on working with health care and managed care, health and other employee benefit plan, insurance and financial services and other public and private organizations and their technology, data, and other service providers and advisors domestically and internationally with legal and operational compliance and risk management, performance and workforce management, regulatory and public policy and other legal and operational concerns.  As a a key focus of this work, she has continuously and extensively worked with domestic and international health plans, their sponsors, fiduciaries, administrators, and insurers; managed care and insurance organizations; third party administrators and other health benefit service providers; hospitals, health care systems and other health care providers, accreditation, peer review and quality committees and organizations; billing, utilization management, management services organizations, group purchasing organizations; pharmaceutical, pharmacy, and prescription benefit management and organizations; consultants; investors; EMR, claims, payroll and other technology, billing and reimbursement and other services and product vendors; products and solutions consultants and developers; investors; managed care organizations, self-insured health and other employee benefit plans, their sponsors, fiduciaries, administrators and service providers, insurers and other payers, health industry advocacy and other service providers and groups and other health and managed care industry clients as well as federal and state legislative, regulatory, investigatory and enforcement bodies and agencies.

Her experience includes more than 35 years of leading edge work for employer and other plan sponsors, plans and their fiduciaries, insurers, third party administrators, health care clearinghouses and other health care, insurance and other data and technology providers, and others on health and other employee benefits design, administration, compliance, and policy including decades of work on fiduciary compliance and risk management; eligibility, coverage and other plan mandates; administrative simplification and transparency; PBM, pharmacy and pharmaceutical management and regulation; surprise billing and other non-par provider; direct provider, vendor and other credentialing, contracting and management; and other managed care and insurance; high deductible, minimum or level premium, captive and other non traditional funding; and agency and private audits, investigations and enforcement; and other insured and self-insured health benefit contracting, design, administration, regulation, fiduciary and other liability managment, and other design, compliance, risk management, defense, and operations solutions.

She also has extensive experience helping health care systems and organizations, group and individual health care providers, health plans and insurers, health IT, life sciences and other health industry clients prevent, investigate, manage and resolve  sexual assault, abuse, harassment and other organizational, provider and employee misconduct and other performance and behavior; manage Section 1557, Section 504, Civil Rights Act and other discrimination and accommodation, and other regulatory, contractual and other compliance; vendors and suppliers; contracting and other terms of participation, medical billing, reimbursement, claims administration and coordination, Medicare, Medicaid, CHIP, Medicare/Medicaid Advantage, ERISA and other payers and other provider-payer relations, contracting, compliance and enforcement; Form 990 and other nonprofit and tax-exemption; fundraising, investors, joint venture, and other business partners; quality and other performance measurement, management, discipline and reporting; physician and other workforce recruiting, performance management, peer review and other investigations and discipline, wage and hour, payroll, gain-sharing and other pay-for performance and other compensation, training, outsourcing and other human resources and workforce matters; board, medical staff and other governance; strategic planning, process and quality improvement; meaningful use, EMR, HIPAA and other technology,  data security and breach and other health IT and data; STARK, ant kickback, insurance, and other fraud prevention, investigation, defense and enforcement; audits, investigations, and enforcement actions; trade secrets and other intellectual property; crisis preparedness and response; internal, government and third-party licensure, credentialing, accreditation, HCQIA and other peer review and quality reporting, audits, investigations, enforcement and defense; patient relations and care;  internal controls and regulatory compliance; payer-provider, provider-provider, vendor, patient, governmental and community relations; facilities, practice, products and other sales, mergers, acquisitions and other business and commercial transactions; government procurement and contracting; grants; tax-exemption and not-for-profit; privacy and data security; training; risk and change management; regulatory affairs and public policy; process, product and service improvement, development and innovation, and other legal and operational compliance and risk management, government and regulatory affairs and operations concerns. to establish, administer and defend workforce and staffing, quality, and other compliance, risk management and operational practices, policies and actions; comply with requirements; investigate and respond to Department of Insurance, Board of Medicine, Health, Nursing, Pharmacy, Chiropractic, trucking, alcohol and firearm, and other licensing agencies, Department of Aging & Disability, FDA, Drug Enforcement Agency, OCR Privacy and Civil Rights, Department of Labor, IRS, HHS, DOD, FTC, SEC, CDC and other public health, Department of Justice and state attorneys’ general and other federal and state agencies; JCHO and other accreditation and quality organizations; private litigation and other federal and state health care industry actions: regulatory and public policy advocacy; training and discipline; enforcement;  and other strategic and operational concerns.

Former lead advisor to the Government of Bolivia on its Social Security Privatization reform, miss Stamer also has extensive legislative and regulatory affairs experience on federal, state and international employee benefits, healthcare, workforce, education, insurance, data privacy and security, antitrust, and other regulations and reforms.

In addition, Ms. Stamer contributes her time and leadership to numerous policy, professional, civil and other organizations, Ms. Stamer currently or previously served as the Scribe leading annual agency meetings on HIPAA and other issues with the Department of Health and Human Services; leadership Council Representative, speaker, author and faculty lead for the American Bar Association (“ABA”) Joint Committee on Employee Benefits; the ABA International Section International Employment Law Committee and International Life Sciences Committee Chair; the ABA Tort Trial and Insurance Practice Section Medicine and Law Committee Chair and Employee Benefits and Worker’s Compensation Committees Vice Chair; the ABA Health Law Section Managed Care & Insurance Interest Group Chair and Risk Management Interest Group Chair; the ABA RPTE Employee Benefits & Other Compensation Group Chair and Welfare Benefit, Fiduciary Responsibility, and Plan Terminations and Transactions Committees Chair; Vice President and Executive Director of the North Texas Health Care Compliance Professionals Association; a Southwest Benefits Association Board Member; a SHRM Consultants National and Region IV Board Chair; WEB National Board Member and Dallas Chapter President; National Kidney Foundation of North Texas Board Member and Compliance Chair; Richardson Development Center (now Warren Center) for Children Early Childhood Intervention Agency Board President; a North Texas United Way Long Range Planning Committee Member; and other leadership involvement in a broad range of other professional and civic organizations.

Author of hundreds of highly regarded works on health and other benefits, human resources, health care, insurance, data privacy and security and other related concerns, examples of these publications include “Transparent PBM Contracting,” “ACOs, Direct Contracting: Legal & Practical Challenges For Employers, Providers & TPAs,” “The Medicare Advantage Contracting Manual,” “Third Party Administrator (TPA) Contracting Principles and Strategies and a multitude of other publications and presentations. 

For more information about Ms. Stamer or her health industry and other experience and involvements, see www.cynthiastamer.com or contact Ms. Stamer via telephone at (214) 452-8297 or via e-mail here.