RBP Strategic Partners, the Key to Long-Term Group Medical Success

The ClaimDOC Sales Team frequently runs across brokers and consultants who have been told very black and white versions of building out a referenced based pricing (RBP) solution for their client. Some programs are pre-packaged vendor stacks with little opportunity for broker input. These off-the-shelf solutions are geared for and generally only competitive in the under 150 employee market. The other end of the spectrum is completely open architecture solutions with no meaningful input from the RBP vendor on what will be the optimal combination. Consultants are told they need to shop for the TPA, PBM, risk, and compliance to complete the RBP offer. This reflects a lazy approach by the RBP vendor, lacks a strategic vision, and should be avoided. 

ClaimDOC offers a flexible solution that is Better than BUCA. A comprehensive group medical solution and strategy. Who cares? The answer lies in how credible you feel the RBP solution should be in solving the areas of quality, cost, flexibility, member support/legal, compliance, and metamorphism. Any TPA can hang a shingle and call themselves an RBP player, and there is little barrier to entry for a startup to reprice claims and tout savings. These solutions lack situational expertise developed from years of hands-on experience with the layers of RBP that all lead back to risk and client satisfaction. Ultimately, to craft a long-term plan, you need to focus on the components that define a long-term strategy for RBP success.

Choice & Quality: 

The area frequently lost in a RBP purchase is finding a provider that fits based on a spectrum of desired preferences. It is often assumed members can access any provider they wish, and costs will just be less, but many providers require a hands-on approach, the focus of our Provider Relations Team. Each member’s situation is different, and having a team who reaches out to the providers, and confirms the payment process, reasons, objectives, and payment timing is very important. Furthermore, a strong embedded Centers of Excellence (COE) program will direct members to the highest quality providers, circumvent provider resistance areas when necessary, and remove inappropriate care through a focus on 70% of plan spend from 7% of the membership, is critical. 


The net cost to the plan sponsor and member is key. ClaimDOC audits all facility claims and audits professional claims over $2,000. This is critical and unique to confirm the bill is legitimate and fair. Upcoding, errors, and fraud are all present in the billing process, and without a proper review, the employer and employee funding is not applied efficiently. The reinsurance vendor must dig into the RBP methods and the proven value of all the component partners, set risk appropriately, integrate and interact with the TPA and RBP vendor on settled and unsettled claims and reflect, through an experience-driven risk assessment, the provable value of strategic reference based pricing. 


Key to any RBP plan selection is how flexible group medical partners are in adjusting to the known and unknown. The healthcare system is changing and, in many ways, not for the better. Consolidation is making the facilities and BUCA’s more powerful and profitable, and to get fair pricing, you must be aggressive and nimble. Integration of RBP, PBM, compliance, risk, member support, virtual, legal, new ideas and niche players, is critical to the plan’s long-term success, and the underestimated and often unfairly commoditized piece is the right TPA selection.

Member Support / Legal:

A member must know they are liable for what is on the Benefits Summary, period. They must know the entirety of the benefit plan offering is working together as a team, with a common goal of support in daily interactions, balance bills, quality access, and the RBP vendor is liable for the claim for the life of the claim. Each of the components must understand the other, the value of the RBP approach, and what their role is in the overall outcome of a successful plan


RBP developed from a broken healthcare system. Short of that system fixing itself, RBP will have an important place for many employers. ClaimDOC is interested in setting a fair reimbursement, watching the employer dollars, supporting the members, interacting with providers, and partnering with quality component players that help shape a Better than BUCA experience and outcome. We are eager to learn, share, and incorporate and integrate the partners that form this strategic RBP approach. A VC that owns all the components is not working in your best interest as you must be able to plug and play new and better ideas that adjust to the ever-changing healthcare environment. Static is useless.

RBP has moved past the focus on just cost. The market can incorporate new ideas that help drive better costs and quality in all areas of the plan, and more will be developed. ClaimDOC is an exceptional RBP partner in service, tools, outcome, vetting, and confirming quality partners. The goal at ClaimDOC is to engage clients in an efficient and functional solution to put more money in the pockets of their employees. Focus on our core strategy and partner with complementary vendors that drive at the ultimate goal, but don’t complicate the experience with unnecessary add-on services

One of the things I really appreciate about our solution is we do not take a penny from strategic partners. Leadership believes that if it is right for the client, we support it for the right reasons, not to make money. In a market full of middling that hurts the end consumer, it is a novel concept not to be greedy when promoting cost containment. There is a better solution. Strategic RBP from ClaimDOC is Better than BUCA.

We look forward to working with you.