New User? Register now

Medicare Reference-Based Pricing

Repricing Claims Based On Medicare Rates

Doctors and hospitals that accept Medicare reimbursement agree to fixed prices set by CMS (the Centers for Medicare and Medicaid Services) based on the providers costs - for the services and treatments they provide to Medicare patients. Those prices are typically a fraction of the amounts that insurance companies or private-pay patients pay and those higher prices continue to increase at an average of more than three times the rate of inflation every year.

With Medicare Reference-Based Pricing, payers (self-funded employers, health plans, etc.) of all sizes can get in on the savings too, enabling them to control their costs both short and long-term.

Some payers use our Medicare Reference-Based approach for all their claims for Medicare-covered services, others for their out-of-network claims, for hospital or physician claims only, or for specific services like dialysis.

Here's how it works. We work with the payer to determine the multiple of Medicare rate they will pay usually between 1.2 to 2.0 times the Medicare rate - for the services their employees/members receive. Then, when a plan member accesses care and the provider submits a bill to the payer, HHC reprices the claim based on the multiple set by the payer.

Keep in mind, not all providers will accept the repriced bill as payment in full. In these instances, the provider can pursue the unpaid balance from the plan member. When clients request, we will even work to secure reductions in the amount the member has been billed. Their members just call us directly for guidance and support.

In addition to repricing claims and providing patient advocacy and support, our clients can take advantage of our appeal support, plan document consulting, negotiation of claims for non-Medicare covered services, reinsurance relationships and member educational material development.

Contact Us to see the huge savings that Medicare-Based Reference Pricing can provide.