Reference Pricing of Health Care Deliverables

Abstract

Embodiments of methods and systems for providing a payer with a platform for reference pricing of health care deliverables are disclosed. One method includes identifying a set of one or more health care deliverables to which reference pricing is to be applied, and setting a reference price for each health care deliverable of the set. For this embodiment, setting the reference price includes providing the payer with analysis of negotiated rates for the health care deliverable across at least one of geographies, demographics, and centers of excellence, and allowing the payer to set the reference price for each health care deliverable based on the provided analysis. The method further includes receiving a health care deliverable request from a user who is covered by the payer, retrieving the set reference price corresponding to the health care deliverable request, and providing the set reference price or out-of-pocket cost to the user.

1 . A computer-method of providing a payer with a platform for reference pricing of health care deliverables, comprising:
 identifying a set of one or more health care deliverables to which reference pricing is to be applied;   setting a reference price for each health care deliverable of the set, comprising;
 providing, by a platform server, the payer with analysis of negotiated rates for the health care deliverable across at least one of geographies, demographics, and centers of excellence; 
 allowing the payer to set the reference price for each health care deliverable based on the provided analysis; 
   receiving, by the platform server, a health care deliverable request from a user who is covered by the payer;   retrieving the set reference price corresponding to the health care deliverable request; and   providing the set reference price to the user, or an out-of-pocket cost to the user, wherein the out-of-pocket cost is based on the set reference price.   
     
     
         2 . The computer-method of  claim 1 , further comprising providing, by the platform server, a list of available providers for providing the health care deliverable request. 
     
     
         3 . The computer-method of  claim 1 , further comprising identifying, by the platform server, one or more populations of users having identified characteristics, and providing the reference pricing to the populations of users having the identified characteristics. 
     
     
         4 . The computer-method of  claim 1 , further comprising identifying, by the platform server, one or more populations of users having identified characteristics, wherein the populations of users having the identified characteristics are excluded from the reference pricing. 
     
     
         5 . The computer-method of  claim 4 , wherein the identified characteristics comprise at least one of a qualification based on age, diagnoses, prior health care utilization, locations of care, geoaccess. 
     
     
         6 . The computer-method of  claim 1 , wherein the health care deliverable comprises a health care service. 
     
     
         7 . The computer-method of  claim 1 , wherein the health care deliverable comprises one or more therapeutics. 
     
     
         8 . The computer-method of  claim 1 , wherein the health care deliverable comprises equipment. 
     
     
         9 . The computer-method of  claim 1 , wherein the health care deliverable comprises an episode of care, wherein the episode of care comprises a plurality of health care deliverables components. 
     
     
         10 . The computer-method of  claim 9 , further comprising identifying reference prices at centers of excellence (COE), wherein a total cost of the episode of care is covered by the payer if the user receives the episode of care from at least one COE, and a selected base reference price is covered by the payer if the user receives the episode of care from a provider that is not a COE. 
     
     
         11 . The computer-method of  claim 1 , further comprising providing, by the platform server, the payer with a total cost of the reference pricing of the health care deliverables, comprising estimating a number health care deliverables to be utilized by users of the payer over a period of time, and calculating the total cost based on the estimated number and the set reference price of each health care deliverable. 
     
     
         12 . The computer-method of  claim 11 , wherein the total cost additionally accounts for saving shared with the users, and modifications to amounts each user pays over the set reference price. 
     
     
         13 . The method of  claim 12 , wherein the total cost additionally accounts for liability caps of the users. 
     
     
         14 . The computer-method of  claim 1 , further comprising selecting a liability cap for the user. 
     
     
         15 . The computer-method of  claim 1 , wherein the reference price for each health care deliverable is adaptively calculated based on changes to health care deliverables pricing over at least one of time, pricing information received from health care providers and centers of excellence (COE), demographics, health of population, geography of population, health benefits, health care utilization, and geoaccess, and negotiated rates at the COE. 
     
     
         16 . The computer-method of  claim 1 , wherein setting a reference price for each health care deliverable of the set further comprises:
 identifying and grouping users;   analyzing geoaccess of the users;   factoring in adjudication capabilities of a health plan of the payer;   influencing the reference price based on cost saving desired by the payer;   analyzing an ability to obtain pricing information in advance of receipt of each of the health care deliverables.   
     
     
         17 . The computer-method of  claim 1 , further comprising applying the reference price to components of a health care deliverable or to combinations of health care deliverables. 
     
     
         18 . The computer-method of  claim 1 , further comprising displaying the out-of-pocket cost of the health care deliverable to the user. 
     
     
         19 . The computer-method of  claim 1 , further comprising displaying a negotiated rate of the health care deliverable request to the user with a designation of whether the negotiated rate is above or below the set reference price. 
     
     
         20 . The computer-method of  claim 1 , further comprising determining a difference between a negotiated rate for a health care deliverable request and the set reference price of the health care deliverable, and at least one of:
 crediting the user with the difference or a portion thereof;   billing the user for the difference or portion thereof;   adjusting the user's deductible or health reimbursement or equivalent account;   adjusting at least one of a debit card, a credit card or other financial instrument or account;   adjusting payer benefit or incentive program balances;   adjusting the user's health insurance premiums;   adjusting the user's payroll;   applying secondary insurance to the difference.   
     
     
         21 . The computer-method of  claim 1 , further comprising:
 receiving a search request from a user for pricing of a health care deliverable;   retrieving a health care deliverable reference price;   providing the health care deliverable reference price to the user, or an out-of-pocket cost to the user, wherein the out-of-pocket cost is based on the health care deliverable reference price;   providing a list of providers of the requested health care deliverable across a variety of geographies.   
     
     
         22 . The computer-method of  claim 1 , further comprising the platform providing the payer with accrued saving to the payer based on utilization of the platform for reference pricing of health care deliverables. 
     
     
         23 . The method of  claim 1 , further comprising:
 receiving claims paid;   verifying that a reference pricing policy has been properly applied to the claims paid;   alerting the user of any erroneous applications of the reference pricing policy.   
     
     
         24 . A computer-method of a platform for displaying pricing of health care deliverables, comprising:
 receiving, by a platform server, a search request from a user for pricing of a health care deliverable;   informing, by the platform server, the user regarding the reference pricing or out-of-pocket costs for the health care deliverable;   retrieving, by the platform server, a health care deliverable reference price, wherein the health care deliverable reference price has been set based on a payer analyzing costs for the health care deliverable across at least one of geographies and demographics;   providing, by the platform server, the health care deliverable reference price or an out-of-pocket cost to the user, wherein the out-of-pocket cost is based on the health care deliverable reference price.   
     
     
         25 . The method of  claim 24 , further comprising:
 identifying capabilities of a user device; and   adapting the displaying of the pricing of health care deliverables or out-of-pocket costs to the user based on specific capabilities of the user device.   
     
     
         26 . The computer-method of  claim 24 , further comprising the platform providing the user with accrued saving based on utilization of services with reference prices. 
     
     
         27 . The computer-method of  claim 24 , further comprising informing the user regarding alternatives to the health care deliverable. 
     
     
         28 . The computer-method of  claim 24 , further comprising showing the user their out-of-pocket cost after applying the health care deliverable reference price and other healthcare benefits for multiple providers of the health care deliverable. 
     
     
         29 . The computer-method of  claim 24 , further comprising displaying a negotiated rate of the health care deliverable to the user with a designation of whether the negotiated rate is above or below the health care deliverable reference price. 
     
     
         30 . The computer-method of  claim 24 , further comprising determining a difference between a negotiated rate for the health care deliverable and the health care deliverable reference price, and at least one of:
 crediting the user with the difference or a portion thereof;   billing the user for the difference or portion thereof;   adjusting the user's deductible or health reimbursement account;   adjusting at least one of a debit card, a credit card or other financial instrument or account;   adjusting at least one of a payer benefit or incentive program balances;   applying secondary insurance to the difference;   adjusting the user's health insurance premiums;   adjusting the user's payroll;   applying secondary insurance to the difference.   
     
     
         31 . The computer-method of  claim 24 , further comprising adaptively updating the health care deliverable reference price for each health care deliverable as changes occur with at least one of the time, pricing information received from health care providers, demographics, health of population, geography of population, health benefit, utilization, geoaccess, and negotiated rates at centers of excellence. 
     
     
         32 . The computer-method of  claim 24 , further comprising applying the reference pricing to components of a health care deliverable or to combinations of health care deliverables. 
     
     
         33 . The method of  claim 24 , further comprising:
 receiving claims paid;   verifying that a reference pricing policy has been properly applied to the claims paid;   alerting the user of any erroneous applications of the reference pricing policy.   
     
     
         34 . A computer-method of providing a payer with a platform for reference pricing of one or more health care deliverables, comprising:
 receiving, by a platform server, a reference price for each of the health care deliverables;   providing, by the platform server, the payer with a total cost of the reference pricing of the health care deliverables, comprising;   estimating a number of health care deliverables to be utilized by users of the payer over a period of time; and   calculating the total cost based on the estimated number of health care deliverables and the reference price of each health care deliverable;   wherein members include persons for whom the payer provides health care benefits.   
     
     
         35 . The computer-method of  claim 34 , further comprising identifying, by the platform server, one or more populations of users having identified characteristics, and providing the reference pricing to the populations of users having the identified characteristics. 
     
     
         36 . The computer-method of  claim 34 , further comprising identifying, by the platform server, one or more populations of users having identified characteristics, wherein the population of users having the identified characteristics are excluded from the reference pricing. 
     
     
         37 . The computer-method of  claim 34 , wherein a total cost estimate provided to the payer accounts for saving shared with the users, and modifications to amounts each user pays over the set reference price. 
     
     
         38 . The computer-method of  claim 34 , wherein the reference price for each health care deliverable is adaptively calculated based on changes to health care deliverables pricing over at least one of time, pricing information received from health care providers, demographics, health of population, geography of population, health benefit, utilization, geoaccess, and negotiated rates at centers of excellence. 
     
     
         39 . The computer-method of  claim 34 , further comprising applying the reference price to components of a health care deliverable or to combinations of health care deliverables. 
     
     
         40 . A system for reference pricing of health care deliverables, comprising:
 reference pricing server operative to identify a set of one or more health care deliverables to which reference pricing is to be applied;   reference pricing server operative to set a reference price for each health care deliverable of the set, comprising the reference pricing server operative to;
 provide the payer with analysis of negotiated rates for the health care deliverable across at least one of geographies, demographics, and centers of excellence; 
 allow the payer to set the reference price for each health care deliverable based on the provided analysis; 
   reference pricing server operative to receive a health care deliverable request from a user who is covered by the payer;   reference pricing server operative to retrieve the set reference price corresponding to the health care deliverable request; and   reference pricing server operative to provide the set reference price or an out-of-pocket cost to the user, wherein the out-of-pocket cost is based on the set reference price.   
     
     
         41 . A system for displaying pricing of health care deliverables, comprising:
 a reference pricing server operative to receive a search request from a user for pricing of a health care deliverable;   the reference pricing server operative to inform the user regarding the reference pricing for the health care deliverable;   the reference pricing server operative to retrieve a health care deliverable reference price, wherein the health care deliverable reference price has been set based on a payer analyzing costs for the health care deliverable across at least one of geographies and demographics;   the reference pricing server operative to provide the health care deliverable reference price or an out-of-pocket cost to the user, wherein the out-of-pocket cost is based on the health care deliverable reference price.   
     
     
         42 . A system for providing a payer with a platform for reference pricing of one or more health care deliverables, comprising:
 a platform server operative to receive a reference price for each of the health care deliverables;   the platform server operative to provide the payer with a total cost of the reference pricing of the health care deliverables, comprising;   estimating a number of health care deliverables to be utilized by users of the payer over a period of time, wherein users include persons for whom the payer provides health care benefits; and   calculating the total cost based on the estimated number of health care deliverables and the reference price of each health care deliverable.   
     
     
         43 . A program storage device readable by a machine, tangibly embodying a program of instructions that when executed by the machine cause the machine to perform a method of providing a payer with a platform for reference pricing of health care deliverables, comprising;
 identifying a set of one or more health care deliverables to which reference pricing is to be applied;   setting a reference price for each health care deliverable of the set, comprising;
 providing the payer with analysis of negotiated rates for the health care deliverable across at least one of geographies, demographics, and centers of excellence; 
 allowing the payer to set the reference price for each health care deliverable based on the provided analysis; 
   receiving, a health care deliverable request from a user who is covered by the payer;   retrieving the set reference price corresponding to the health care deliverable request; and   providing the set reference price or an out-of-pocket cost to the user, wherein the out-of-pocket cost is based on the set reference price.