Reference Based Pricing (RBP) will allow ERISA Plans to apply a specific reimbursement strategy for claims payment. Summary plan description language is critical to support RBP. The Medicare based reimbursement formula will replace reliance upon a discount system which does not provide clients with risk and claim management techniques, individual claim data, or a dependable solution to reduce future stop loss premiums and claims exposure. The RBP application to claims utilizes Medicare as the prevailing cost base allowing clients to develop a reimbursement formula applicable to hospital services and professional charges. In circumstances where Medicare reimbursement is not available, such as pediatrics, hospital cost data are used in determining a reimbursement. All necessary data elements to re-price either based upon Medicare or hospital cost data are maintained by PNA.
RBP can replace the traditional PPO and/or be used effectively on Out-of-Network claims.
PNA will provide a staff of experienced professionals in use of Medicare data to benchmark specified claims. Medicare benchmarking has been an integral part of PNA cost containment solutions for the past 15 years. Additionally, the staff possesses in-depth knowledge of all self-funded components involved ranging from stop loss to third party administration responsibilities, the result is a practical and effective solution both user and vendor friendly.