PSM of TN – PPO and RBP – Plan Highlights

 PPO & RBP 

CONTACT US AT: 

866-815-6001

EMAIL: @detegohealth.com

Preferred Provider Organization (PPO) 

A Preferred Provider Organization (PPO)is a type of medical plan in which coverage is provided to participants through a network of selected health care providers, such as hospitals and physicians. Enrollees may seek care outside the network but pay a greater percentage of the cost of coverage than within the network. 

Reference-Based Pricing (RBP)

Reference-Based Pricing (RBP) is a reimbursement method that uses Medicare reimbursement rates (or a derived equivalent) as a reference and prices claims based on a multiple of that rate. RBP is an alternative to traditional healthcare pricing, where reimbursement rates for medical services are determined by a specific reference point instead of a provider's billed charge, which can vary widely, even within the same geographic area. 

Don't be misled into thinking hospitals charge the same rate for every patient. Using advanced Reference-Based Pricing methodologies, Detego Health® understands the rates each hospital charges and how to secure the best possible price for services. We've done the research so you don’t have to.

Plan Designs with Low Copays that Serve All

Nationwide Network Access:

PHCS

First Health Network

HealthSmart

PHCS Practitionary and Ancillary

A Complete Network of Benefits Partners 

Live Daytime Customer Service and 24/7 Access to Member Portal Services 

What is Reference-Based Pricing (RBP) in Healthcare?

Reference-Based Pricing (RBP) is a smart way for employers to control healthcare costs. Instead of paying whatever a hospital or doctor charges, RBP sets a predetermined price — usually based on a multiple of what Medicare pays for the same service.

This means that, instead of using traditional PPO network rates, the plan uses a clear reference point (like Medicare rates) to determine what it will pay. This can help employers and employees save money and better understand what they’re paying for.

Reference Point:
RBP uses Medicare reimbursement rates or other benchmarks as the starting point for pricing healthcare services.

Set Pricing:
Plans pay a fixed percentage above the benchmark. For example, your plan may pay 120% of Medicare’s rate for a surgery, instead of the full hospital charge.

Negotiation with Providers:
Providers can accept the set amount or negotiate a different rate. This helps keep costs fair for everyone.

Cost Transparency:
Members know how much their plan will pay, which makes healthcare costs clearer and more predictable.

Lower Healthcare Costs:
RBP helps employers and employees save money by avoiding overpriced bills and limiting what the plan will pay for each service.

More Transparency:
Members can see exactly how pricing is set, helping them make informed decisions about care.

Greater Provider Choice:
RBP plans often allow you to see any provider — you’re not restricted to a narrow network.

Improved Employee Satisfaction:
With lower premiums and out-of-pocket costs, employees often feel more satisfied with their health plan.

Reference-Based Pricing is becoming more popular for employers who want to cut healthcare costs while giving employees more clarity and freedom. If you’re looking for a way to spend less on medical claims and make healthcare pricing more transparent, RBP could be a good fit for your organization.

Similiar terms: Reference-Based Pricing, RBP healthcare, RBP health plan, healthcare cost containment, Medicare benchmark pricing, employer health plans.

PHCS. Practitioner and Ancillary

Via Multiplan's PHCS Practitioner & Ancillary Network, access is expanded to include urgent care, labs, and a variety of other ancillary services. If you are looking for something specific that you can't find, our Care Guides will be happy to help you.

PHCS -Preferred HealthCare System

Multiplan's PHCS Network is the largest independent, nationwide primary preferred provider organization (PPO). It is the preferred choice for health plans wanting a provider network with flexibility to meet their unique needs. Plans get administrative ease without sacrificing provider access, savings, and quality for health plan members.

First Health Network 

First Health Group Corporation provides national and regional Preferred Provider Organization (PPO) network access and other cost containment programs to help our clients manage employee benefit plans. We offer one of the largest directly contracted national PPO networks, the First Health Network, and leading regional networks, such as Cofinity and First Choice of the Midwest. We also offer a national dental network, and we have a variety of products to reduce the cost of out-of-network claims, including per claim negotiation, Medicare-based repricing and supplemental networks.

HealthSmart

 For employees, their health and the health of their families is a priority. In many cases, they rely on their employers to provide benefits with access to quality care at an affordable price. That’s no small task. The HealthSmart Preferred PPO helps our clients deliver access to a national network of high quality, credentialed providers that can be customized to meet their needs and the needs of their members.

Detego Health Third-Party Administrator (TPA)

As a third-party administrator, specializes in De ® tego Health LLC the sourcing and management of health benefits plans. We act as an advocate, working to limit the costs of healthcare without sacrificing quality or access to care. Detego Health: (866) 815-6001 

MyLiveDoc

Telemedicine 

Connect with Board-Certified Physicians, anytime, anywhere in the United States who can diagnose and treat virtually. 24/7 access to primary care, urgent care, and mental health care! MyLiveDoc: (855) 226-6567 

GuideCM

Pre-certification & Case Management

GuideCM is the exclusive Pre-certification and Case Management team for Detego Health® . Pre-certification and Case Management are programs designed to help make sure you get the appropriate medical care at the best cost to you. Our staff works closely with you and your doctor to get the maximum benefit from your health benefit plan.

Call GuideCM: (866) 837-1714 

NaviClaim 

Member Advocates & Balance Bill Services 

NaviClaim is the exclusive Member Advocate for Detego Health . ® NaviClaim reviews your bill for accuracy and re-prices it to ensure fair reimbursement. Once re-priced, NaviClaim sends the claim to your third-party administrator (TPA) for processing.

Call NaviClaim: (866) 837-1436 

ScriptAid:

Prescription Access Assistance 

ScriptAide is the exclusive Pharmaceutical Advocate for Detego Health and provides prescription access assistance to ® our members. Our Pharmaceutical Access Coordinators specialize in researching ways to help our members get the brand-name medications they need and save them money. ScriptAide works directly with the member to see if they can get their medications through one of our 3 access programs: the Personal Importation Program (PIP), the manufacturer's Patient Assistance Program (PAP), and the Self-pay Personal Importation Program (SPIP).

Call to check if you qualify to participate in one of our programs.

Call ScriptAide: (866) 837-1515 

Green Imaging

Affordable Medical Imaging 

Helping patients make the most informed decision about MRIs, CTs and other imaging procedures, Green Imaging provides a single cash-pay price for services with no surprise fees. Green Imaging: (844) 968-4647

Diathrive

Diabetic Solutions 

Helping patients make the most informed decision about MRIs, CTs and other imaging procedures, Green Imaging provides a single cash-pay price for services with no surprise fees.

Call Green Imaging: (844) 968-4647 

Connect DME

Medical Equipment and Services

Connect DME offers home medical equipment and services at dramatically lower costs. Connect DME also offers in-home or in-facility sleep studies. The Home Sleep Study is performed by a respiratory therapist and interpreted by a board certified sleep physician.  

Medalist RX

Pharmacy Benefits 

Whether its retail pharmacy, mail-order or specialty pharma, MedalistRx has you covered for all your Rx needs 24/7.

Ventegra

We offer innovative, cost-saving solutions beyond the PBM model. Our revolutionary healthcare model goes beyond traditional pharmacy benefit management to help build efficiencies, lower costs, and improve the overall quality of care. 

Concierge Services

Detego Health LLC has Care Guides available at (866) 815-6001 from 7:00AM - 5:00PM CST to support your every need.   

Member Portal 

When you are logged on, you can view EOB's and claims, download forms, access your plan documents and much more! 

ScriptAid

Prescription Access Assistance  

Our Pharmaceutical Access Coordinators work directly with the member to see if they can get their medications through one of our 3 access programs: the Personal Importation Program (PIP), the manufacturer's Patient Assistance Program (PAP), and the Self-pay Personal Importation Program (SPIP). 

GuideCM:

 Pre-certification & Case Management  

ScriptAide Pre-certification and Case Management are programs designed to help make sure you get the appropriate medical care at the best cost. Our staff works closely with you and your doctor to get the maximum benefit from your health benefit plan.

Green Imaging

Affordable Medical Imaging 

Helping patients make the most informed decision about MRIs, CTs and other imaging procedures, Green Imaging provides a single cash-pay price for services with no surprise fees. Green Imaging: (844) 968-4647