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Reference Based Pricing

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.

Learn More

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.