A TPA with whom The Phia Group has worked closely for many years recently began to utilize its proprietary reference-based pricing model, whereby the TPA would perform claims repricing and patient advocacy. Since reference-based pricing entails paying claims at Medicare rates, it follows that plan documents must be amended prior to a given plan being able to utilize the service. After all, if the plan does not have the rights to pay based on Medicare rates, the plan cannot compliantly do so.
Conveniently, the TPA was a client of The Phia Group’s Phia Document Management (PDM) service, through which plan documents can be efficiently and seamlessly created online, with access to The Phia Group’s template language materials. This TPA was adding five groups to its reference-based pricing platform, and needed plan documents completed within the week to manage some high-profile renewals.
Using the PDM service, the TPA was not only able to compile and draft the plan documents it needed, but it was able to ensure that those plan documents included some of the best reference-based pricing language in the industry. Built into The Phia Group’s template materials are options for reference-based pricing language, which gives the plan all the rights it needs to pay based on Medicare and other criteria, or pay negotiated rates as necessary as well. To this day, the TPA has not experienced a challenge to that reference-based pricing language.