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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) 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.

With Medicare Reference-Based Pricing, payers (self-funded employers, health plans, etc.) can get in on the savings too. In these circumstances, the payer has determined to pay the provider a multiple of the Medicare rate (usually 1.2 to 2 times the rates set by Medicare.)

Payers can use HHC Group's Medicare Reference-Based approach for all claims for Medicare-covered services, out-of-network claims, for hospital or physician claims only, or for specific services like dialysis.

Here's how it works. A plan member accesses care, and the provider submits a bill to the payer. The payer, in turn, works with HHC, and we determine the Medicare rate and reprice the provider's bill accordingly.

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.

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