Reinforce the value of your PPO network with out-of-network pricing.
Using Medicare-based pricing for out-of-network claims can create pricing parity between in-network and out-of-network claims, stabilizing the planʼs overall cost.
- Direct relationship between local plan members
- Better savings than a typical PPO network offers
- Plan members can continue to use any provider with complementary out-of-network program
FULL PPO REPLACEMENT.
See any medical provider with no PPO network restrictions.
Using Medicare as a basis for pricing allows plan members to see any medical provider at a consistent, predictable plan payment with no PPO network necessary.
- No provider restrictions; plan payments configured by group, claim type, and geography
- Balance-billing handled through direct provider education & negotiation
- Program cost is far less than most PPO network fees
PARTIAL PPO REPLACEMENT.
Choose which providers to access with no PPO network restrictions.
Similar to Full PPO Replacement, this alternative allows the use of a facility- or professional-based PPO network while using reference-based pricing for all other claims.
- Group can choose whether to use reference-based pricing for Facility or Professional claims
- Strong complement to partial PPO network
- Can be coupled with Settlement Agreement Network approach to reduce balance-billing
CONTRACTED PROVIDER PRICING.
Reliable contracted pricing for your provider agreements.
For your contracted providers, Medicare pricing is used to appropriately price claims where the contractual agreement is based on a chosen level of Medicare.
- Allows the health plan to configure pricing at a provider-specific level, based on Medicare and health providers.
- Works in tandem with all other ClearHealth services: out-of-network and PPO replacement
- Enables the health plan to address providers reluctant to continually service its members without having an agreed upon rate established, and is custom to the provider-specific agreement established