Over 1,000 entities have attempted a Reference Based Pricing model. Most every one has been and is deficient or inadequate creating legal exposure and much stress and heartache to patients, plan sponsors/employers. There is much to be gained through a Reference Based Pricing vendor who can perform this duty comprehensively and as a fiduciary. There are only a couple Reference Based Pricing vendors in the United States that perform the needed process properly. Our recommended vendor is fully vetted and one of the successful Reference Based Pricing vendors.
The Audit Program is set up to recognize the Medical Provider’s actual cost to deliver the service and to allow a fair margin above that cost. The Audit Program does not use billed charges as a starting point.
Instead it utilizes transparent and recognized industry sources, with a particular focus on Medicare and the annual cost reports many Medical Providers report annually to the Centers for Medicare & Medicaid Services (CMS).
- GUARANTEE -
If our fee eliminates a financial benefit for the plan on ANY claim, then ALL usual & customary vendor services on that claim will be FREE to the plan.
- CASE STUDY -
• Member treated at a hospital facility in central California
• Member was treated for chronic cholecystitis (chronic gallbladder issues common with recurring gall stones)
• Member received surgery which was charged at $15,825.44 (billed charges)
• Hospital facility then unbundled the same charges and billed them separately aka Unbundled Charges
• Total billed charges: $56,849.64
• Total Amount Plan Saved: $50,944.34
These are charges that never should have been included in the bill. We then reduced
the bill even further per its audit process in accordance with the Plan language, saving the Plan a total of