AMPS Reference Based Reimbursement (RBR)
As the cost of health care continues to rise, the ACA has mandated coverage but has not provided an answer to combat the rising costs. With no pricing transparency and increases of more than 70% in premiums over the last eight years – there doesn’t seem to be any relief on the way.
Is there a solution? Yes, the AMPS Health Plan, or Reference Based Reimbursement (RBR). AMPS RBR is a health plan design and benefit payment methodology that provides reimbursement based on absolute fair market value of services rendered. AMPS RBR stabilizes and/or improves benefits for employees while increasing employee satisfaction and morale – while at the same time reducing the cost of benefits and improving operating margins.
TBG with AMPS CASE STUDY #1 | Small Employer
This small employer client consists of roughly 120 employees. They implemented the Advanced Medical Pricing System in 2014. If you look at the AMPS Additional Savings over the PPO Column you will notice that in 2014 this client saved $72,943.97 over what the PPO would have allowed. In 2015, they were able to save $274,318.00 over what they would have paid with the PPO discount.
TBG with AMPS CASE STUDY #2 | Large Employer
This large employer client consists of roughly 500 employees. They implemented the Advanced Medical Pricing System in 2012. If you look at the AMPS Additional Savings over the PPO Column you will notice that in 2014 this client was able to save $1,095,733.00. In 2015, they saved $1,276.662.00 over the PPO discount.
The AMPS health plan solution provides a plan reimbursement methodology based on the fair market value of the services rendered allowing optimization of every health care dollar. The methodology is fair, transparent and therefore, a sustainable solution.
AMPS Medical Bill Review
AMPS provides no risk, medical bill review services that are guaranteed to deliver unparalleled savings and unrivaled protection to our clients. The AMPS team of physicians reviews each claim line-by-line, and our integrated legal services indemnify customers against risk and handle appeals if necessary. Our unique, proprietary and HIPAA-compliant technology allows us to review medical bills and supporting clinical records quickly, seamlessly and with an unprecedented level of accuracy.
The AMPS Margin Erosion Calculator allows users to visualize the erosion of profit margin as benefits increase over time. Plug in real data, Annual Revenue, Benefit Expense (including pharmacy), Pre-tax Margin, and estimated tax rate – users can choose to use the default assumptions for revenue and expense growth, or plug in custom numbers. The tool will chart the estimates over 5 years and create a pdf report sent via email.
A Pharmacy Benefit Manager (“PBM”) is a third party administrator of prescription drug programs. The PBM is primarily responsible for processing and paying prescription drug claims. The PBM is also responsible for developing and maintaining the formulary contracting with pharmacies, and negotiating discounts and rebates with drug manufacturers. Today, more than 210 million Americans nationwide receive drug benefits administered by PBMs.
For a small fee, the PBM enables plan sponsors and individuals to obtain lower prices for their prescription drugs through price discounts from retail pharmacies, rebates from pharmaceutical manufacturers, and the efficiencies of mail-service pharmacies.
A Preferred Provider Organization (“PPO”) is a network of medical providers that offer a discount on the cost of their services and goods in return for more business. Most PPO networks, offer a disruption and cost-savings analysis to determine if the company’s current network is a good fit for its existing health plan. If the current network is not a good fit, there are many nationwide PPO networks to consider.
Contracting with more than one PPO might be the answer for clients that have divisions/employees around the country. One PPO network might be strong in one geographical region and weak in another. Each health plan differs and provides different needs which is very important in finding the best PPO network for the plan. At TBG we strive to make sure you are matched up with the perfect fit for the requirements of the plan.
TBG has agreements with several PPO networks. If TBG does not currently use a particular PPO network, we will reach out and start the agreement process with such network if that is the best fit for the group. Below are several links to the websites of those PPO networks we currently utilize: