Reference Based Pricing
Lately, all eyes are on Reference Based Pricing (RBP). In fact, it was standing room only at the Reference Based Reimbursement (RBR) discussion panel last month in Austin at SIIA's biggest event of the year. SIIA’s National Educational Conference & Expo is the world’s largest event dedicated exclusively to the self-insurance/alternative risk transfer industry. RBP was also a hot topic at the recent SPBA conference in Minneapolis, and it’s clear that many TPA’s are embracing a multitude of RBP strategies, most with great success.
There are three methodologies currently in the marketplace for RBP: (1) Straight Medicare reimbursement (100%), (2) Medicare PLUS (i.e. 125%, 150%, 200% of Medicare), and (3) Cost PLUS. Cost PLUS models are losing traction simply due to transparency. Most Cost PLUS models have a black box approach to pricing, based on a combination of proprietary factors, indexes, data sets and benchmarks. This makes the pricing much more difficult to defend. As such, Medicare PLUS as the reference for RBP is the most widely accepted choice because it is the only nationally recognized and accepted index. That is one of the many reasons why ClearHealth Strategies specializes in Medicare PLUS RBP – the “Surf” in this equation.
Deerwalk, Inc. is a Population Health Analytics company with a next generation, cloud-based analytics and reporting platform. ClearHealth has partnered with Deerwalk to fully integrate our Medicare Reference Pricing data into the Plan Analytics application. What does this mean and why is it important? Because it allows employers, payers and brokers to run on-the-fly reports and ad-hoc “what if” scenarios at the claim, group, provider and network level (in vs out) as well as by service type. It allows users to analyze each group or line of business that is considering a Medicare pricing strategy and compare allowed amounts to five increments of Medicare reimbursement (100%, 125%, 150%, 175%, and 200%) in seconds. It's that fast. It allows users to determine providers and service categories with the highest allowed amounts compared to Medicare at different levels and evaluate network exclusions, narrow network, steerage targets, and plan design changes. Put another way, it’s the “Turf”, the second part of the equation.
Many payers, employers and brokers are pushing to analyze full PPO replacement models, eliminating networks completely, narrow network models, as well as more traditional Out-of-Network replacement models. Every group deserves a customized program that suits their specific risk tolerance. The “Surf & Turf” combination of ClearHealth and Deerwalk gives these stakeholders the ability to run all of these scenarios, in real time, against claims history in Deerwalk’s Plan Analytics Web UI, and gain these insights in seconds. Quite simply, it’s a game changer!
What if Medicare doesn't have a price?
ClearHealth has a team dedicated to keeping up to date with the most defensible and reputable indexes of pricing for claim's such as pediatric vaccines, molecular pathology, behavioral health etc. where Medicare does not have pricing, and these values are also shared in Deerwalk’s Plan Analytics application.
Pricing – The Surf & Turf Combo
Choose ClearHealth for RBP on out-of-network claims, and Deerwalk’s Plan Analytics application can be included in the % of savings fee. Or choose Deerwalk for Population Health Analytics, and the Medicare Reference Pricing analytics tool can be included in the application maintenance fees.
To learn more about Deerwalk's Population Health Analytics solutions, please visit www.deerwalk.com, or click below to request a demo: