How Reference-Based Pricing Impacts Healthcare Expenses: 6 Questions to Answer

Healthcare costs continue to rise as organizations strive to provide quality care to their employees while managing rising costs. Reference-based pricing (RBP) has received significant attention in recent years. With RBP, employers can regain control over their healthcare spending by challenging the traditional reimbursement model. To assess the potential impact of this pricing model on your organization, it is crucial to ask the right questions before adopting it. As we evaluate the adoption of a reference-based pricing model, we need to consider seven key questions.

Reference-based pricing

How does reference-based pricing differ from traditional pricing?

In order to effectively evaluate RBP’s benefits, one must understand its fundamental principles and how it differs from traditional pricing methods. Unlike negotiated rates with insurance carriers, RBP sets reimbursement rates based on a reference point, like Medicare rates or a percentage above the provider’s costs. The purpose of this approach is to bring transparency to healthcare expenses and control their costs.

How will reference-based pricing affect our current network?

A key consideration is how RBP will affect your organization’s existing network of healthcare providers. Assess the compatibility of your current provider network with RBP and its potential impact on employee access to care. Providing quality healthcare while reducing costs is crucial.

Should employees be educated and informed about reference-based pricing?

Employees may resist the transition to RBP if they are not adequately informed and educated about it. Ensure that your communication plan addresses the concerns and questions of your workforce. To gain employee buy-in and support, emphasize the benefits of RBP, such as cost savings, expanded provider options, and increased transparency.

What are the implications of reference-based pricing?

Even though RBP has the potential to lower healthcare costs overall, employees’ out-of-pocket costs must be considered. Consider how deductibles, copayments, and coinsurance might change. To ensure a smooth transition, communicate these changes to employees transparently.

What can we do to ensure compliance with state and federal regulations?

State and federal regulations governing healthcare reimbursement must be thoroughly understood before RBP can be implemented. Ensure your organization remains compliant throughout the transition process by partnering with legal and compliance experts. The process involves evaluating and mitigating any potential legal risks.

How can balance billing issues be addressed?

Balance billing, where patients are billed for the difference between the reference-based reimbursement and the provider’s charges, can pose challenges when adopting RBP. Explore strategies to address potential balance billing issues, such as negotiating with providers to waive balance billing or implementing a robust patient advocacy program to support employees in resolving billing disputes.

Can we measure reference-based pricing’s success and impact on healthcare costs?

In order to assess the effectiveness of RBP, metrics and measurement tools must be established. Indicators such as employee satisfaction, healthcare spending, and health outcomes can be defined as key performance indicators (KPIs). Regularly evaluate and monitor these metrics to gauge the success of the RBP model and make adjustments as necessary.

Using a reference-based pricing model can help your organization lower healthcare expenses. In order to determine if RBP is right for your organization, ask these seven essential questions. Engage in thorough planning and communication to ensure a successful transition by seeking guidance from industry experts. While prioritizing your employees’ health and well-being, you can unlock significant savings with careful consideration and a well-executed strategy.

What role does CMSPricer play in customizing RBPs?

In most cases, RBP plans are administered by a third-party administrator (TPA). CMSPricer, a SaaS-based Medicare repricing system, enables TPAs to provide in-house rate-based pricing (RBP) based on CMS Medicare rates and customize any variances from those rates.

CMSPricer allows providers and facilities to calculate their Medicare allowable fees more efficiently. This web-based pricing tool uses accurate CMS Medicare allowable rates to avoid overpayments and underpayments.

Organizations can significantly reduce healthcare costs by leveraging CMSPricer’s RBP model and self-service interface. Are you wondering how CMSPricer is designed to be the most user-friendly? Click here for more information.