Reference Based Pricing

A comprehensive savings strategy tailored to fit plan goals.

Competitive savings. Fewer appeals. Reduced surprise balance billing. All integrated with your current systems for minimal process disruption.

Reduced Balance Billing Infographic

 

Unmatched flexibility and experience

Zelis supports the payer’s ability to administer any iteration of Reference Based Pricing (RBP), whether for certain out-of-network claims only or as a full or partial network replacement. Zelis RBP delivers a sustainable savings strategy through unmatched flexibility with pricing, network configuration, member advocacy and support services all tailored to meet unique plan needs.

Pricing Options

Unlike other RBP approaches, Zelis provides a choice of pricing options and guidance for the best pricing strategy.

  • RBP for Out-of-Network Savings: Zelis recommends using our proprietary market-based fee schedule, Established Reimbursement Schedule (ERS)
  • RBP for PPO Replacement: Zelis recommends using our proprietary Medicare Pricing Solution (MPS)

Comprehensive support services for sustainable RBP

Clients may choose to customize their Zelis RBP strategy with a range of innovative tools and services designed to advocate for members, improve transparency, manage risk and drive savings.

  • Pre-Service Payer and Member Support
  • Claim Settlement and Inquiry Management
  • Member Advocacy and Legal Support

 

Surprise Balance Billing Solution

Zelis Is Your Surprise Balance Billing Partner

Reduce the pain of surprise balance bills

Even when patients carefully choose in-network facilities for treatment, they can still face balance bills if treated at the facility by out-of-network providers. In fact, 7 in 10 individuals with unaffordable medical bills did not know the provider was out-of-network at the time they received care.

Zelis Surprise Balance Billing Solution is an excellent option for plans seeking to address this growing concern. We leverage our in-house legislative expertise and our proprietary fee schedule to yield plan savings while reducing the risk of surprise balance billing.

Surprise Balance Billing Solution Components

  • Legislative Toolkit: Developed by Zelis in-house legislative experts and legal team, used with our member advocacy and claims settlement programs
  • Established Reimbursement Schedule (ERS): Zelis’ compliant, proprietary fee schedule provides a market-based, non-arbitrary and defensible reimbursement with a low appeal rate and high retained savings
  • Member Financial Advocacy Program: Zelis advocates for your members, offering proactive member outreach and working to resolve balance bill disputes
  • Claims Settlement Service: leverages in-house legislative expertise and reduces the risk of balance billing through post-payment settlement