Understanding Medicare Reference Based Pricing

Healthcare pricing is complex and inconsistent. With a limited processing time window, claims are often managed without much analysis, objectivity, or accuracy, leading to out-of-control healthcare costs. Medicare Reference-based Pricing (RBP) is one strategy that can help our clients realize dramatic healthcare savings by understanding the true cost of care.

At its core, Medicare RBP is a cost-containment strategy that eliminates rate negotiation between employers and healthcare providers by paying doctors, labs, clinics, and hospitals a percentage of an established benchmark—published in the Medicare fee schedule. Most often, the reimbursement rate is 120 percent to 200 percent of Medicare pricing for a given service. Depending on the claim, savings can range between 45%-75% or more.

Medicare Fee Schedules

Accuracy in repricing a claim starts with having the most up-to-date fee schedule. The Medicare Fee Schedule is a complete listing of payment policies, payment rates, and other provisions for services by doctors or other providers and suppliers and determines the maximums used to reimburse providers on a fee-for-service basis. As the government updates the Medicare Fee Schedules, staying on top of those changes is crucial to make sure the fees of a claim are accurate.

Provider Appeals

As Medicare Reference Based Pricing almost eliminates rate negotiation between employers and healthcare providers, it also takes the employer and the patient out of the negotiation process, should a provider appeal the calculation of the reimbursement rate or reject payment at the employer's designated Medicare multiple. HHC Group provides comprehensive appeal and negotiation support with the provider.

Patient Advocacy

Medicare Reference Based Pricing can significantly reduce Balance Billing—when a provider bills a patient for the difference between the provider's charge and the allowed amount the insurance pays. If Balance Billing does occur, that's where patient advocacy services can assist by getting the provider to eliminate the balance bill and accept the payment in full or accept a reduced payment amount. Additionally, a patient advocate needs to set realistic expectations with the patient and communicate frequently during the resolution process.

H.H.C. Group understands that every payer's needs and situations are unique. That's why Our Medicare Reference Based Pricing strategies are completely customizable to best meet each payer's individual needs. No matter your Medicare RBP strategy, H.H.C. Group can reprice claims, advocate for your members, and provide balance billing support that helps deliver significant healthcare savings and increased transparency.

Get in touch today by calling 301-960-7092, or by scheduling a meeting.