What is the difference between reference-based pricing and fair market pricing?

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Welcome to Ask an Adviser, EBN’s weekly column in which benefit brokers and advisers answer (anonymous) queries sent in by our readers. Looking for some expert advice? Please submit questions toaskanadviser@arizent.com. This week, we asked Arthur Chapman, a principal with Reliant Health Partners, to weigh in on the following:What is the difference between reference-based pricing and fair market pricing?

Since employee health benefits typically are in the top five ofprofit-and-loss expenses在美国,降低成本的呼声很高。当供应商认为有必要提高价格时,他们在其特定地区收取的所谓惯常、习惯和合理的服务价格就会上涨,增加了通胀压力。

In recent years, referenced-based pricing (RBP) has made inroads into self-fundedmedical plans,定价与a挂钩Medicarebase rate with an additional percentage added on. These plans have helped to bend the medical cost curve downward for self-funded payers. RBP may be included in the plan design as the method of paying out-of-network (OON) claims only or it may be used to replace the primary network.

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这种对成本的积极影响在许多情况下带来了抵消性的干扰,因为医疗提供者有时会向计划成员支付余额,从而将成本从计划转移到成员身上。根据计划和/或RBP供应商提供的支持,这可能会给成员带来巨大的财务压力,从而导致集团内部的不满。

城市对面的两家医院可能有非常不同的成本结构,这导致在提供相同服务时,一家医院的收费更高。应用医疗保险费率,再加上每个计划设计的百分比,可能会向医院a提供合理的支付,而不是医院B,从而产生余额账单。

Fair market pricing (FMP) provides an alternative solution for payment of medical coverage for members of self-funded plans and bends the cost curve downward as well. FMP can be employed to price only the OON claims or replace the network and reprice all claims. The basis for FMP is reported data, relying on geographic and provider-specific benchmarks.

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In the case above with two hospitals performing the same procedure across town from each other, the claim pricing is customized to account for different cost structures. This leads to a higher acceptance rate and avoids some of the disruption that accompanies balance bills.

Employing FMP clears the way for the covered member to choose any doctor or facility without the constraints that may be in place with the traditional network or wrap network – and all at zero-cost to the beneficiary.

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