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


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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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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