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Medicare Reference-Based Pricing

Medical 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.

Addressing Provider Questions
There are times when providers question the amount they have been paid for those services. When they do, we provide written communications for the payer to send to the provider explaining the basis on which the amount they have been paid has been calculated. If the provider continues to challenge the amount being paid, we take appropriate steps based on direction from the payer.

Continuing Member Education for Program Success
The first step in successfully implementing a MRBP program is educating plan enrollees before the plan goes into effect. It is important that they understand what MRBP is, why it makes sense to use MRBP as the basis for paying claims, and what the benefits of paying providers based on MRBP are for them. It's equally important that they learn what to do if a provider sends them a bill for the balance of the provider's original charge not being paid by their plan. We are available to assist in this crucial initial member education.

The second step is keeping this information top-of-mind through periodic communications and other reminders. That way if the enrollee ever gets balanced billed, they'll know just what to do Alert us using the HPGPS app or website or Call the HHC Group 800# helpline - and what we do - assign them an HHC attorney personal patient advocate who will work with them to resolve their claim. Of course, we keep the enrollees and the plan up to date on our progress every step of the way. Once again, we are available to assist in the creation of the periodic communications and other reminder devices.

Member Communications and Engagement
Member engagement and communications are the keys to the ongoing success of any MRBP Plan. H.H.C. Group's new Health Plan GPS (HPGPS) user friendly mobile app and website is ideal for member education and communication, increasing member engagement and satisfaction, and reducing both plan and member healthcare costs for MRBP Plans. With HPGPS members can identify providers to use, track their benefits status, notify their Plan of any balance bills they receive and much, much more.

Contact Us to see the huge savings that MRBP can deliver and learn more about our member education and assistance programs, and HPGPS, the member communications, engagement and steerage app/website.



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