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Medicare Reference-based Pricing RAND Study

  • by John Danza
  • Jun 11, 2024, 15:04 PM

As a leader in the Medicare reference-based pricing (RBP) space, Context is frequently asked two questions:

  1. What percent of Medicare do our other clients allow?
  2. What percent of Medicare will cause the least amount of disruption to the members and pushback from the providers?

Our answer to the first question is always “payers are all over the map”. We’ve seen as low as 100% and as high as 230%. Our answer to the second question is always “There is no right answer. There are many factors that will drive this. Our recommendation is to work with your highest volume providers to come to an agreement on the percentage.”

Now the RAND Corporation has released a study that may help payers answer the second question. RAND has analyzed private insurer payments from all states except Maryland, and has broken down those payments relative to Medicare allowables. There are a number of conclusions that RAND draws based on geographic region, quality of care, and others. If you are a payer that is heavily involved in Medicare RBP programs, or you’re a payer that is thinking about starting a Medicare RBP program, Context highly recommends that you review the RAND study for guidance on how you might structure your program.

You can find the RAND study at https://www.rand.org/pubs/research_reports/RRA1144-2.html

If you want to know how Context can help you with your Medicare RBP needs, or with your plan’s Payment Integrity needs, please contact us at https://www.context4healthcare.com/about/contact-us/

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