What is Reference Based Pricing?
Reference Based Pricing (RBP) is the amount of money your health plan has determined it will pay for specific medical services. A reference price is often used to ensure that payments to providers are reasonable, this can be any free market price such as KPPFree™ or a commonly know price, such as Medicare.
Medicare is used as a commonly understood language and as a starting point for a mutual negotiation, increasing overall transparency and enhancing patient choice. Under RBP, the provider is reimbursed their current Medicare rate, PLUS an additional amount.
How Does RBP work?
- A plan that includes Reference Based Pricing has standard benefits, such as copays, deductibles, and coinsurance.
- When you visit your doctor, they will file a claim using the EDI# on your medical ID card, just like they would normally.
- When the claim is processed, the reimbursement will be based on the RBP amount determined by your plan benefits and the type of provider.
- This amount is the provider’s current Medicare rate, PLUS an additional amount.
- Oftentimes, your doctor agrees that this is a fair and reasonable reimbursement!
- If your doctor does not agree to the reimbursement, please reach out to us. Balance billing is not the end of the conversation, there are resources available to assist you.
- Out-of-Network RBP Patient Guide
- No Network RBP Patient Guide
- Out-of-Network RBP Know Before You Go
- No Network RBP Know Before You Go
- RBP Pre-Service Advocacy Form
- No Network Provider Introduction Letter
Examples of Reference Prices Include:
- Free Market Price, such as KPPFree™, online retailer, or another market price option.
- Healthcare Bluebook Fair price.
- A percentage above the amount paid to the provider by Medicare
Many benefit plans utilize RBP for out-of-network benefits, or as a replacement for a PPO network. If you have questions about your RBP benefits, please Contact Us.
How do you know if your plan is contracted with a network?
To determine whether your plan has contracted with a PPO network, review the Medical Plan section of your ID card, log in to our Secure Benefit Portal, or contact us.