Whether you refer to it as Reference-Based Pricing (RBP), Medicare Reference, Cost Plus or something else, the important thing is to understand what it is and why it’s being used to lower health plan costs.

​Level-funded health plans with reference-based pricing provide high quality coverage at a lower cost by using Medicare fee schedules as a base. Then they negotiate with hospitals and physicians to determine an acceptable percentage margin over and above Medicare. Margins often fall within a range of 25% to 65%. 

Health care costs have been trending upward for a number of years. Employers in the U.S. expect the cost for medical plans per employee to raise 5.6% on average in 2023, according to Mercer, a human resources consulting firm. This has led many employers to search for affordable insurance options to lower expenses without sacrificing quality for their employees.
 
With traditional group health insurance plans, employers use their bargaining power to purchase coverage from insurance companies at a lower rate than individuals usually pay, and they cover a majority of employees’ premiums. The insurance companies pay employees’ claims using the premiums paid by the employer and keeping all unused premiums for themselves.
 
Level-funded group health plans allow employers to pay for claims themselves, saving money on profits that typically go to insurance companies and are protected by stop-loss insurance that caps their total claims exposure. These plans have become increasingly popular among small employers because they set level monthly payments, the same as a tradition insurance plan. These payments go towards covering the estimated costs of expected claims, administrative costs and stop-loss insurance. But with a level-funded plan, employers can actually see money returned when their group has a healthy, low-cost year.

​For many, the end of the year is a time to slow down, relax and reflect on the year behind us while setting resolutions for the year ahead. At Allied National, our employees are busy paying claims, providing agent support, closing new business and booking renewals. But we still have time to look back at what we accomplished in 2021 and share with our readers what’s ahead for Allied National in 2022. And be sure to take our quick survey at the end for a chance to win an Amazon gift card! 

Preferred Provider Organizations (PPOs) date back to 1980 when the first PPO was organized to provide contracted rate medical care to a health plan. For providing “steerage” toward the medical providers in the PPO network, the providers granted discounted rates for their services to the health plan.

Over the years, PPOs have changed and morphed into multiple variations, but the end result is the same – health plan members are steered toward PPO providers for their medical care and given favorable discounted rates.

The advantage of this type of arrangement is very obvious – it’s price.

It can be upsetting to receive an unexpected bill for medical services. Before you panic, do some research. You need to understand what the bill is for and who really has the responsibility for its payment.
 
This is called balance billing. Balance billing occurs after your insurance company has paid everything it’s obligated to pay – but the provider wants more.
 
For example, if your doctor charges $100 for a service, your insurance company might pay them $70. Who is responsible for the other $30? Is it part of your required out-of-pocket costs (copays, deductibles, coinsurance)?