Overview
Reference-Based Pricing (RBP) means determining a fair price for services by comparing them to Medicare rates. For example, if Medicare sets an X-ray at $100, that’s the fair price under Medicare.
With RBP plans, the allowed amount is typically 150% of the Medicare rate (but this varies), meaning if the same X-ray was priced at or below $150 it would be considered a fair price. This allows patients to see a wider range of providers while still ensuring that the providers are charging a fair price for their services.
RBP calculator
We have a calculator, located on the sidebar in the portal, that helps coordinators determine the allowed amount for most services.
If the provider price is less than the price the calculator provides, they’re all set! The patient can go see that doctor and pay the price determined.
However, if the doctor is charging more than 150% of Medicare, there are additional steps care navigators can take:
Help the member find a different provider who will offer a more competitive price for that service.
If a provider near the member who will give a more competitive price cannot be found, or if there are other extenuating circumstances, coordinators can reach out to the TPA. Depending on the plan’s rules and the circumstances, we may be able to approve the card as an exception.
