Reference Based Pricing
Data Driven Pricing
Reference Based Pricing (RBP), also commonly known as Cost Plus Pricing, offers self-insured plans a defined benefit structure based on more economical reimbursement levels designed to be fair and reasonable to providers based on various pricing data sets, most notably Medicare. (Chart below shows spread in actual hospital costs as reported to the U.S. Government vs. hospital billed charges vs. what PPOs are paying.)
Employers are driving a trend toward alternative medical cost management seeking reprieve from inflated medical pricing and PPO overpayment. It is apparent we are paying too much for our care, and RBP is a solution growing exponentially in use that provides patient’s choice, saves employers money, and provides quality care. RBP eliminates the need for a PPO.
AMPS uses the term Referenced Based Reimbursement (RBR) for its RBP service because while self-funded employers cannot control the prices facilities charge, with AMPS help, they do control what reimbursement is a fair and reasonable payment for services rendered.
Reference Based Pricing
Mike Dendy, provides an overview of AMPS Reference Based Pricing product called Reference Based Reimbursement.
The AMPS Difference
Being a named fiduciary enables AMPS to have responsibility for payment determinations on hospital and physician claims while protecting Health Plan and employee/member assets.
The RBR program is based on Fairness, Transparency, and Reasonability. Through a consistent application of our industry-accepted repricing analysis and decision process, AMPS can create a valid and defensible payment recommendation.
Using a collaborative approach with clients and providers, AMPS RBR strengthens its long-term strategy by modifying behavior through direct communication, education, and inclusiveness.
For every 1,000 employees on an employers’ RBR health plan, this 37% decrease in cost equates to approximately $2,600,000 in savings.
Currently 200+ companies nationwide use AMPS RBR as their health plan, replacing their PPO. Over the last 3 years, AMPS average reimbursement level on hospital claims averaged 156% of Medicare—approximately 37% less than BUCA PPO reimbursement levels.
Introducing Care Connex
AMPS’ RBR solution, Care Connex, brings the pressures of consumerism and the free market to the medical world. Employers set a certain dollar amount—a defined contribution—they will reimburse per procedure based on multiple data points (Medicare being one of many). Patients then connect with an AMPS Care Navigator to find a local provider that will conduct the desired procedure. Cost transparency is thus stimulated by providers.
Care Connex Service & Benefits
AMPS provides TPAs/Brokers with a next-generation portal and analytics platform, which will provide anywhere, anytime visibility into claims flow, performance metrics, and trends. The portal provides on-demand insight for both internal and client review meetings, including performance monitoring, reporting, TAT tracking, claims management, contracting, and pricing.
AMPS’ physician panel reviews every facility and physician claim over a minimum threshold to better ensure accuracy and defensibility so only valid claims are paid.
AMPS provides Members with personal healthcare concierge services, offering a wide variety of care options, deeper/optimized savings, scheduling coordination, and eligibility checking.
AMPS fosters healthy relationships between Groups and Providers, yielding fair payment and minuscule balanced billing for overcharges.
AMPS is an extension of the Group’s Benefits Team, providing proactive outreach, ongoing advocacy, advocate authorization, and credit protection.