When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you’re protected from surprise billing and balance billing.
Out-of-network providers and facilities haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit. Surprise billing is an unexpected balance bill. This can happen when you can’t control who is involved in your care — like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This protection includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
When you get services from an in-network hospital or ambulatory surgical center, certain providers who work there may be out-of- network. In these cases, the most these providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist or intensivist services.
These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.
You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. If your provider asks you to sign a waiver giving up your balance billing rights, you don’t have to sign the waiver. You can choose a provider or facility in your plan’s network.
You’re only responsible for paying your share of the cost (like copayments, coinsurance and deductibles) that you would pay if the provider or facility was in-network. Your health plan will negotiate directly with out-of-network providers and facilities and pay any balance beyond your in-network, cost-sharing expenses. Your health plan generally must:
Visit www.cms.gov/nosurprises for more information about your rights under federal law.
David served as a Regional Vice President of Mercy Health, overseeing risk arrangements for large direct employer contracts in Missouri, Arkansas, and Oklahoma. In this role, he developed patient-centered care management operations and launched a Mercy-owned third-party administrator (TPA) from scratch.
While at Mercy, David led a team that pioneered a new model for risk-sharing with large, self-insured employers using “risk corridors.” This model enabled Mercy to provide employers with a negative trend from year one, with very small trend increases in subsequent years. Leveraging out-sized results, Mercy delivered millions of dollars in savings while earning millions of dollars in shared savings. Central to the success was improving the experience for physicians and patients alike.
During his career at Mercy, David prosecuted over one hundred direct-to-employer contracts, including Walmart, Bass Pro Shops, O’Reilly Auto Parts, Missouri State University, Springfield Public Schools, and the City of Springfield.
A hands-on leader and proven innovator, Larry has made a career developing solutions that improve clinical and financial outcomes for physicians, patients, and payers.
Recognized for his relationship management skills and his capacity to anticipate future trends, Larry has helped bring to market microsurgical procedures, implantable devices, advanced diagnostic imaging equipment, clinical information services, e-clinical trials applications, and most recently, a value-based health benefits solution for self-insured, middle-market employers.
In 2005, Larry founded Vxtra Partners, a special-purpose health benefits solution focused on helping large, independent medical practices improve the cost and quality of their healthcare benefits. His objective was to gain insight into the health insurance industry by working with large medical practices that employed, on average, 250+ FTEs. As a result, Larry recognized the only way to create new-found value was to “start over.”
OneDigital, a national benefits advisory firm with over 75,000 employers as clients, acquired Vxtra Partners in 2023. Proceeds from the sale were re-invested to accelerate the launch of Vxtra Health, a value-based platform offering designed to compete with legacy health insurance companies. The mission of Vxtra Health is to disrupt the self-insured, middle-market employer space by bringing physicians and self-insured employers together in a collaborative, transparent environment.
Jason has provided operational and technical leadership to large health insurance companies and multiple healthcare start-ups. He has operationalized two health insurance companies, taking them from the pre-licensure concept stage to scale and achieving as much as $145M in annual revenue.
Applying Six Sigma methodologies, Jason is a subject matter expert in recognizing and preventing operational challenges before they occur. Leveraging his detailed understanding of healthcare business processes, systems interoperability, data flow, and technical engineering, his endgame is a frictionless experience for each stakeholder.
Jason has a proven track record of attracting experienced talent and is known for his coaching and mentoring skills. He strongly believes in giving back to those in his network who have helped him throughout his career. As a result, he has the capacity to attract the requisite talent to drive operational excellence at any stage.
Pete has developed and managed a wide-ranging portfolio of technological solutions. His career includes senior management roles as a Chief Information Officer, Chief Technology Officer, Chief Information Security Officer, Operational Risk Executive, Data/Analytics Evangelist, and board member. He has held leadership and C-suite roles in both large “Fortune List” companies and small entrepreneurial companies in financial services and healthcare.
Pete is CISA and CISM certified and a founding member of the University of North Carolina Charlotte Cybersecurity Symposium. He holds a co-inventor patent for Risk and Control Assessment and is a past category winner of the Charlotte Business Journal CIO of the Year.
Danielle began her career in the self-insured employer space working as a teenager part-time at a local third-party administrator (TPA). While in college, she interned at a large national TPA that serviced self-insured employers across the US.
Danielle’s career path has provided her the opportunity to become a multidimensional, client-first thought leader. She served as the benefit manager for a large self-funded employer before spending seven years with a national benefits consulting firm. In that role, she served as an advisor for both fully insured and self-insured employers.
Danielle served as the Director of Business Development for Charlotte-based TargetCare, a company that worked with self-insured employers to design and implement preventive health and disease management programs that successfully lowered healthcare costs and improved outcomes.
Danielle’s prior experience at a nationwide TPA, includes managing a multi-million-dollar block of business. Most recently, she worked for a at a venture-backed TPA that was acquired in 2018 by an international insurance conglomerate. She held several senior leadership roles where her responsibilities included, sales operations, implementation, reinsurance, and marketing.
Mike has extensive early-stage experience helping health plans frame up the operational and technology road maps necessary to move from concept to scale. His experience spans working with established and venture-backed health plans, third-party administrators, and industry vendors to help them navigate the challenges associated with product definition, operations, and regulatory complexities.
Mike was one of the first employees of one of the largest venture-backed health-tech start-ups of its time. He was responsible for enterprise readiness, developing key operational processes, and coordinating enterprise-wide planning prior to the company launching its individual and Medicare Advantage health plans throughout the US.
Prior to his experience with venture-backed health plans, Mike held several product-focused positions at Optum, a UnitedHealthcare company. He participated in developing and launching market solutions focused on identifying and engaging populations with complex medical conditions and introducing plan participants to programs that would help them understand and manage their condition better.
Mike currently serves as chair of the Self Insurance Institute of America’s (SIIA) committee on price transparency data. He has been a featured speaker at multiple SIIA conferences. He received training at the University of Pennsylvania in storytelling and design-thinking, a skill he infuses into each of his roles.
Bethnie stepped into her role as Chief Marketing Officer at Vxtra Health with over two decades of experience in post-acute healthcare. Her passion for nurturing physician-patient relationships and crafting strategic marketing campaigns while focusing on championing patient-centric care is second to none.
From managing inpatient authorizations to leading marketing teams across various sectors in the healthcare industry, her wealth of industry knowledge has translated to true success in her marketing endeavors, driving revenue growth for different organizations. Her commitment to creating the healthcare of tomorrow is a testament to her networking skills, research acumen, and strategic expertise. We are proud to have such a results-driven individual on our team to elevate Vxtra Health’s brand awareness and support our future growth.
Jerry has served in both senior executive leadership and strategic consulting roles for large and middle-market self-insured employers. Most recently, he served as the National Benefits Practice Leader for a boutique consulting firm where he was responsible for developing and managing health benefits solutions for an international medical device company, a PE-backed pharmaceutical roll-up, and an international consumer products company. His experience brings a deep understanding of how to manage the contractual complexities of health plan financing, claims administration, provider networks, care management services, and pharmacy benefits management.
Jerry was one of 14 senior management investors who participated in launching Alta Health Strategies, a Warburg Pincus-backed venture that became First Health where he served as Senior Vice President and Eastern Regional Director. One of the first publicly traded managed healthcare companies in the U.S., First Health was acquired by First Data Corporation, a NYSE company, and subsequently by Coventry Health, a wholly owned subsidiary of Aetna at the time.
Coming from a family of innovative physician leaders, Ted has helped create programs that introduce physicians to new technologies and modalities across multiple sub-specialties.
Leveraging his capacity to communicate and bond with “early adopter” physicians, Ted has played an integral role in helping early-stage medical device companies stand up their “education-centered” sales and marketing efforts, a skill that equates to earning trust from the physician community.
Bret joined Vxtra Partners in 2003 after spending 2 years in business-to-business sales in the logistics and supply chain management industry. During his nearly two decades in the employee benefits and insurance space, Bret held Customer Service and Account Management positions before moving into Business Development in 2014.
Over the next decade, Bret has been integral in Vxtra Partners’ shift toward helping private physician practices understand pitfalls of fully-insured and standalone self-funded programs and the advantages of health benefits captives, utilizing data analytics and price transparency.
In 2023, Vxtra Partners’ book of business was acquired by a large national brokerage and Bret assumed the role of Director of Business Development for Vxtra Health. He will use his experiences working with healthcare providers and insurance knowledge to develop relationships with prospective employers, consultants and brokers.
A CPA by training, Tino has served in multiple executive leadership roles for large, independent medical practices. Most recently, he served as chief financial officer of Carolina Urology Partners, a 36-physician urology practice in Charlotte, NC, where he was responsible for all financial operations, data analytics, and contractual relationships.
Prior to Carolina Urology Partners, Tino served as the CEO, COO, and CFO of Central Ohio Urology Group (COUG), a 29-physician urology practice, an independent ambulatory surgery facility, and men’s health center in Columbus, Ohio. Prior to his roles at COUG he served as the CFO for the rehabilitation division of the state of Ohio.
A board-certified adult and pediatric urologist, Dr. Di Loreto brings extensive experience as a specialty-care physician, healthcare innovator, and trusted advisor. His consulting expertise includes medical malpractice, clinical information technology, electronic medical records, regulatory issues, medical practice data, and software development. As a practicing physician, Dr. Di Loreto developed an HCFA-compliant paper-based charting system that incorporated clinical protocols as well as internal audits. Throughout his career he has championed the roll-out of numerous electronic health record systems and ancillary programs.
Dr. Di Loreto has been a consultant and urology advisory panel member for the Food and Drug Administration’s Center for Devices and Radiological Health for more than 30 years. He was the co-founder and president of the Michigan Institute of Urology (MIU), the nation’s first large urology supergroup. Concurrent with his role at MIU, he served as the medical director of Michigan Mobile Lithotripsy, the co-founder and board member of Michigan Cryogenic Equipment Services and Michigan Mobile Urology Services, the co-founder and medical director of Great Lakes Lithotripsy, and chief medical information officer for Integra Connect. He was the chief of urology and past president of medical staff at Saint John Hospital and Medical Center in Detroit, MI.
Dr. Di Loreto served as a board member and Chairman of the Board for St. John Health System in Detroit, MI.
Prior to joining Vxtra Health, Dr. Brown served as Vice President of Clinical Affairs and Managed Care Contracting at Mercy Health, a preeminent integrated health system serving both urban and rural markets in Missouri, Arkansas, and Oklahoma. One of the few financially successful Accountable Care Organizations (ACO’s) in the U.S., Dr. Brown and his team became subject matter experts in the science of collaborating with both independent and employed physicians resulting in lower healthcare costs and a better experience for employers and physicians. As a result, Mercy became an industry leader in executing highly profitable shared-risk contracts with large, self-insured employers as well as in the Medicare Advantage space.
Dr. Brown is responsible for medical oversight of Vxtra Health and for creating and managing medical policies with a focus on incentive-based benefit plan designs, outcome-focused data analytics, and a network offering based on “patient-first” physician collaboration.
A registered nurse with over two decades of relevant experience, Cindi is a highly regarded performance-driven healthcare executive that has spent her career leading efforts to align self-insured employers, physicians, and health systems in ways that overcome the complexities, and realize the opportunities, of value-based care. She is passionate about demystifying the intricacies of healthcare for patients and physicians.
Cindi has led the development and execution of care management solutions for a wide variety of population health and payment model arrangements. This includes direct contract arrangements with employers, partial and full-risk arrangements with Medicare Advantage plans, Medicare ACO models, and quality incentive arrangements with commercial and Medicaid payors. She has developed models in the approach to care management that are evidence-based and rooted in putting meaningful data in the hands of those who can turn it into action.
Her past experiences include being responsible for integrating ambulatory and inpatient care management teams and program management across 300+ employers, four regions, and twenty-one hospital locations. She brings relevant experience in building clinical analytics teams, methodologies for risk segmentation, and sustainable strategies for evaluating clinical and financial outcomes.
Carol has an extensive career in Critical Care Medicine. She has held various leadership roles, including Director of Clinical Applications for a national outcomes database and Director of Case Management for the western division of Hospital Corporation of America (HCA).
With a focus on utilizing the most current patient care modalities, protocols, and technologies, Carol is driven to optimize outcomes. Her strength lies in her unique ability to bring together multidisciplinary clinical and administrative cohorts into a well-organized and functional team. Her collaborative management leadership skills result in a vertical and horizontal integration of each stakeholder, which creates cohesive working environments.
A Six Sigma Master Black Belt, Brian has extensive experience scoping and managing technology transformation for Fortune 100 corporations and early-stage companies alike. He has held corporate leadership roles at Tech Mahindra, GE Energy, CNBC, NBC Universal, Inc., GE Capital, and CIBA Vision.
Brian has served as a trusted advisor to numerous organizations pursuing cloud-first systems architecture, predictive analytics software, complex data management modeling, IoT software, text analytics, digital marketing, digital CRM applications, machine learning, and the utilization of artificial intelligence to improve model-based automated testing processes.
Brian serves as a technology advisor to the Company’s executive management team and Board of Directors.
After practicing interventional cardiology for 17 years and serving as the Chief Medical Officer at Bryan Heart in Lincoln, NE, Dr. Whitney relocated to Gainesville, Georgia, in 2019 to be closer to his family. Dr. Whitney currently practices non-invasive cardiology at the Georgia Heart Institute, part of the Northeast Georgia Health System. He is an active member in Medaxiom, a wholly owned company of the American College of Cardiology.
Dr. Whitney received his medical degree from the University of Nebraska Medical Center and completed his residency at the University of Iowa Hospitals and Clinics. He completed his fellowships in cardiovascular disease and interventional cardiology at the University of Nebraska Medical Center. Dr. Whitney has an undergraduate degree in Chemical Engineering. Building on his interest in the future of data-driven, value-based care, he obtained a master’s degree in business analytics in 2021.
Dr. Whitney is a Fellow of The American College of Cardiology and serves as an Advisory Board member on the American College of Cardiology / Medaxiom Peer Review+, an unbiased clinical performance evaluation and case review service.
Dr. Pender is an accomplished ophthalmic surgeon, innovator, author, and advocate for patients and physicians. He is the founder of the New Hampshire Eye Associates and the founder and medical director of the first state-licensed and Medicare-certified ambulatory surgery center in New Hampshire. After serving as a Principal Investigator for FDA clinical trials of laser vision correction, he launched a facility dedicated to refractive corneal surgery with his colleagues in New Hampshire.
Dr. Pender has authored two books supporting the sacred nature of the patient-physician relationship. “Rebuilding Trust in Healthcare: A Doctor’s Prescription for a Post-Pandemic America” examines both the internal and external factors that have led to distrust and how to reestablish much-needed trust in healthcare. “Standing Up & Speaking Out for Patients & Doctors: First Steps Toward Focused Healthcare Solutions” comprises a collection of Dr. Pender’s published writings to explore new ways better to serve patients in a rapidly changing healthcare environment.
