Reference-Based Pricing

Reference-Based Pricing

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Reference-Based Pricing (“RBP”) is not a traditional medical plan design because it generally does not include a provider network. Instead of contracted rates between the network and provider, it uses a government-based fee schedule. This strategy allows the employer to cap medical procedures that can vary greatly between providers. MAP® Health has a better approach to Reference-Based Pricing.

To provide value to RBP, we have added our MAP® high-performance provider network which measures physicians’ and facilities’ outcomes. To reduce pharmacy costs up to 35%, we offer MAP® Rx. The biggest challenge for RBP is the provider balance billing from providers and facilities. Our Direct Pay payment approach targets facilities with balance billing concerns to eliminate or reduce balance billing issues.

5 Keys to Implementing a Successful Value-Based RBP Program

01. Understanding How Our Value-Based RBP Program Works

RBP is an option to control costs for self-funded groups with rising medical costs. RBP deals with the issues that are driving up medical costs — the provider network’s financial arrangements. MAP® Health will work with the group’s consultants to project the provider network’s financial costs over the coming years. The solution is to drop the network arrangement and substitute a known financial arrangement that everyone can understand, such as a government-based fee schedule. Most companies that use a transparency fee schedule are solely focused on pricing, not value. As a user of MAP® RBP, you will receive a transparency fee schedule and our MAP® high-performance provider network. Our RBP program adds value to pricing through high outcome physicians and facilities recommendations and through our dedicated medical staff working with participants to ensure they get the correct diagnoses and/or direction to medical care.

02. Using Market Analysis

The goal is to correctly measure the potential savings of moving to a value-based RBP program. This includes determining which facilities can be negotiated with and which will be Direct Pay. We look at the top 20 utilized facilities (hospitals, ambulatory surgery centers, others) of each employer group to determine which are RBP-friendly providers.

03. Discovering How MAP® RBP Program is Different

All of our the medical management functions are fully integrated to achieve a “Value-Based” program under our Mission Control Operation. We named our operation Mission Control because our medical staff manages the navigation of care from the beginning to the end based on physician outcome information. Our mission is to get the best outcome on every case.

Medical Advocate Program® (“MAP®): When a participant speaks to a MAP® Nurse Advocate, more than 40% of the time, the Nurse Advocate provides a different direction. It is shocking but true — all too often the participant’s self-diagnosis or medical need may have been incorrectly identified. Based on the participant’s location and medical needs, our Nurse Advocate and Research Analyst identify the top 5% to 10% of providers in the community. Through this unique approach, only 15% to 20% of physicians nationwide meet our MAP® criteria. While that means 80% to 85% of physicians do not make the cut, it also means our participants get the very best medical care. MAP® can assist with any type of medical care: primary care, specialist services, mental health, diagnostic tests, and second opinions. learn more »

MAP® Rx: Our medical staff reviews the participant’s prescriptions to determine if they are taking the correct medications at the most cost-effective prices. Our program can save participants money on thousands of name-brand and generic medications. We work with leading pharmaceutical companies to provide affordable solutions such as patient assistance programs, grants and other alternative resources.. learn more »

UM/Precertification: In addition to providing medical necessity review, the program is integrated with MAP® to ensure participants make informed decisions about their medical care. We speak directly with the participant on every medical precertification. Through our medical review process, we also determine if the participant needs case management or the MAP® Rx program for prescription medication review.. learn more »

MAP® Case Management: When a participant faces a serious illness, a Certified Case Manager (CCM) works directly with them and their family to ensure they understand how to navigate the healthcare system to achieve the best outcomes. Our resources include CCM Nurses, Research Analysts, Pharmacy Professionals, and Medical Directors. learn more »

Direct Pay: This is a proactive, coordinated payment to physicians and facilities at or before the time of service. It is a different and efficient way of paying providers. The bundled payment saves the participant money and eliminates any balance billing issues. This program allows an employer to customize the plan benefit design to encourage participant engagement with MAP® to make wise healthcare decisions financially (price) and outcome-based (quality). Price + Quality = Value. A plan benefit design discussion can help employers understand the pros and cons of adding a “physician only” medical network.

Note: We have the ability to perform provider negotiation under a single payer agreement or a direct contract between the employer and provider.

Optional Services:

Repricing Claims (Optional Service): We have the ability to reprice claims or the broker may use a vendor of their choice. Regardless of who does the claims adjudication, MAP® Health audits payments on a monthly basis and discusses the results with the TPA/broker/employer.

Legal Support (Optional Service): When we are not using Direct Pay, we do not have balance bill issues or have a need for legal support; we only provide legal support for balance billing issues. We also can provide assistance with summary plan description language for plan benefit designs.

04. Identifying the Employer’s and Employee’s Role

Education: We will educate both the employer and employee to make sure they understand their roles when obtaining medical care. Since this program is not an insurance product, participants will need to understand how to talk to their physicians and facilities. Also, they will need to understand the coordination of care in order to ensure that the provider gets paid. All of us will need to work together to reap the benefits of this program.

Plan Benefit Design: We can assist with creating financial incentives for the program and communicating them to participants.

On-Going Communications: We do not educate only once. Each time participants call MAP® RBP or MAP® RBP makes an outreach call to participants, they will be informed on how to navigate the healthcare system. Consistent communication is vital for the success of this program.

Reporting and Managing: We regularly monitor claims to hold everyone accountable. We have on-going discussions on how participants are navigating the healthcare system. We identify what is working and what is not working.

05. Obtaining the Best Medical Care

The goal of using RBP is to reduce medical costs and improve the medical outcomes of the participants. By selecting physicians with the most favorable outcomes and directing participants to the proper facilities, we can reduce medical expenditures without sacrificing care or affordability.

A partnership with MAP® RBP will maximize success and minimize balance billing issues associated with RBP. We are a medical management and educational solution that consistently educates and engages participants in the program. MAP® RBP is a value-based solution.

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