Medicare Referenced-Based Repricing

The US Healthcare landscape is more complex and experiencing more change than ever before. Plans are now realizing that significant savings can only be achieved through fundamental change, and reports show that out-of-network claims are billed at several hundred, if not thousand percent above the Medicare allowed rates. Medicare Reference-Based Repricing solutions are quickly becoming the standard for out-of-network claims or as a complete PPO replacement for many plans.

 The advantages of implementing a Medicare Reference-Based pricing program are as follows:

  • Save significant dollars on current out-of-network charges: at 200% of Medicare, average Plan savings is 50%+.
  • Emphasize accountability and better healthcare decision making within membership to increase In-Network utilization.
  • A solution that drives deeper savings below Wrap Networks and Claims Negotiation services, AND carries a much lower % of savings fee.
  • Medicare is a known quantity and provides transparency to the provider community vs. proprietary solutions.

What Makes Relevant’s Out-of-Network Solution Different?

  • Complete flexibility in the configuration of the program as it relates to applying various percentages of Medicare to various situations, specific providers, provider types, geography, etc.—even down to the line level of medical claims.
  • Appeals Management Services: included within the risk-free contingency fee. Less than 5% of claims result in an appeal.
  • Rapid turnaround times and electronic, automated claims transfers lead to efficiencies and lower administrative fees.
  • Expertise in creating proper and effective algorithms for filling the ‘gaps’ for non-Medicare coding, and ensuring that proper Summary Plan Document language exits to support the program and protect the plan and its members.
  • Our repricing engine utilizes extensive data sets to determine the prevailing price.

As noted, average savings using a base of 200% of Medicare rates is approximately 43% off average “allowed amounts” (or nearly 50% from billed charges). Most clients choose to use a basis of 150% of Medicare rates. At this percentage, savings are more in the range of 57% off “allowed amounts” (or nearly 65% off of billed charges). However, because our repricing model is built on Medicare’s rates vs. a % of billed charges, savings could be higher or lower dependent upon the specific billing practices and/or demographics of the provider.

We understand that all clients are not alike. That is why we will work with you to build a tailored solution that meets your specific needs. This is a turn-key cost management solution.

Savings Example: 10,000 Members

  • Estimated Annual BILLED charges = $70,000,000
  • Estimated Out of Network BILLED Charges = $3,500,000
  • Estimated Savings:
    – @ 200% of Medicare = $1,750,000 or 50%
    – @ 150% of Medicare = $2,205,000 or 63%

The Medicare plus percentage is determined by the client. Different percentages can be applied by provider type, specific provider, region, etc.

“Being able to configure the program based on carve outs, group or claim type, provider-specific and state specific rules, geography, and type of care gives our clients great flexibility in how we choose to implement the program.  This solution has enabled our company to increase savings in our cost containment program by almost 50%!”  Operations Manager—TPA