Author: Ginger Barrientez

What Is Reference Based Pricing?

As the cost of healthcare continues to rise, employers search for new ways to reduce those costs while maintaining the quality of care they want for their employees.

One approach that’s not so new to the scene but gaining in popularity as a cost containment strategy is Reference-Based Pricing (RBP).

RBP seeks to provide the true cost of care administered by a healthcare provider or facility by replacing the antiquated percent off billed charges that are based on an ambiguous chargemaster or fee schedules that beg the question of the source(s) for the procedural prices.

Reference-Based Pricing, also commonly referred to as Medicare Reference Based Pricing, Reference Based Reimbursement and Metric Based Reimbursement, is a strategic alternative to a traditional PPO network, replacing High Deductible Health Plans (HDHP).

RBP comes in many forms, basing the reimbursement amount on some type of Medicare-based rate, cost of charges or percent of savings, and it can be structured with or without a contract with a hospital and/or individual provider.

When an employer-sponsored, self-funded health plan transitions from its current PPO plan to an RBP plan, they will realize the benefits of lower provider reimbursements, increased plan savings, increased satisfaction, and possibly healthier employee populations with care being more affordable.

Before a self-funded group makes the move to this model, it’s important to understand how an RBP program works.          

There are several options for adopting an RBP plan, and depending on the partner you choose, such as Payer Compass, you will encounter different approaches to navigating this reimbursement strategy.

Through the support and guidance of a Third-Party Administrator or Benefit Advisor, a self-insured group can select their optimal RBP plan. Factors such as plan locale, RBP climate, and risk, among others, should be considered in determining the best RBP model:

  • Full PPO Replacement Model – RBP for all claims
  • OON Model – RBP for Out-of-Network claims only + PPO network for all other medical care
  • Hybrid Model – Narrow network or Direct Contracting + RBP
  • Carve-Out Model – RBP for specialty, carve-out services only

Approaches to RBP differ based on the parties involved – TPA, Benefit Advisor, Stop-Loss Carrier, RBP vendor, Employer – and their preferences.

Payer Compass’s turnkey RBP program, INNOVATE360, focuses on three pillars:

  1. Accurate Claim Pricing: Claim pricing encompasses not only pricing/repricing a healthcare claim, but also editing, gap-filling for claims that seem unlikely to price, and contract management.
  2. Proactive Patient Advocacy: Patient Advocacy includes education of the plan member and provider, gaining acceptance of the plan rate by the provider, balance billing communications and correspondence, and care coordination when needed.
  3. Effective Balance Billing Strategy: The balance billing strategy consists of upfront review and alignment of all plan docs, escalated balance billing support and the oversight of appeals determination and fiduciary responsibility.

Now that we’ve established what a comprehensive RBP program is, let’s see what it looks like from the eyes of the Plan Administrator and Plan Member.

For Example:

Let’s say Widgets, Inc. implements an RBP plan, replacing its HDHP. Widgets educates its plan members upfront to familiarize them with this new concept (your RBP partner should have education materials for use).

Jane Doe, who works at Widgets, needs a knee replacement. Jane asks her friends and family about reputable providers in the area and decides to contact Dr. Smith. Once Jane sets an appointment with Dr. Smith, she contacts her Patient Advocate to notify them of her scheduled visit.

If Dr. Smith’s office has questions about Jane’s RBP plan, the office can reach out to her Patient Advocate who can provide education and answers to Dr. Smith’s office to ensure they understand and accept the plan rate.

Jane successfully undergoes knee replacement surgery, and the claim is processed in line with her RBP plan, without any additional out-of-pocket expenses from Jane to Dr. Smith – this is the case for 99% of all scenarios experienced by Payer Compass clients.

Alternate Scenario Outcome:  

If the situation were different, and Dr. Smith sent Jane a bill for an amount over the agreed upon plan reimbursement rate, known as a balance bill, Jane would first notify her Plan Administrator.

The Plan Administrator would help Jane verify that the difference was a legitimate balance bill, and not an owed copay or deductible. If they found it to indeed be a balance bill, the Plan Admin would contact Jane’s Patient Advocate who would then go to work for her to address the outstanding balance with Dr. Smith.

In this case, additional balance billing strategy may be activated including appeals support and fiduciary responsibilities to resolve the scenario.

Reimbursement solutions like Reference-Based Pricing provide a valuable, sustainable method for employers to provide the benefits they want to give their employees, without crippling their budgets.

Some self-insured groups are hesitant to migrate to this type of model, mentioning fears of risk, upsetting plan members with a new concept, and lacking knowledge of industry partners. However, with education and building trusted partnerships, the outcome is bright.

Still have questions? Contact Payer Compass for the answers, and also check out our RBP Readiness Checklist

Payer Compass Announces Appointments of Chief Financial Officer and Chief Revenue Officer

PLANO, Texas, June 12, 2019– Payer Compass, a leading provider of healthcare reimbursement technology and price transparency solutions, is proud to announce the appointment of two key additions to its leadership team. Matthew Thompson will serve as the company’s Chief Financial Officer and Slayton Gorman will serve as the Chief Revenue Officer.

“We are extremely proud to have Matthew and Slayton join our team,” said Payer Compass CEO Greg Everett. “They will each bring significant experience in their areas of expertise to Payer Compass. Their combined talents coupled with their proven track records of success for developing new clients, markets and teams will be invaluable as we continue to expand our footprint.”

As CFO, Matthew Thompson will oversee accounting and financial reporting, as well as business and financial analysis. Mr. Thompson joins Payer Compass with more than 20 years of financial management experience. He most recently served as CFO of HealthSmart Holdings. Prior to that, he served as CFO of American CareSource Holdings, Inc., an operator of urgent care centers and a national network of ancillary healthcare providers. In addition to his many years of experience in healthcare, he has held financial management positions with Tyler Technologies, Inc. and started his career with Ernst & Young LLP. He earned a Bachelor of Business Administration in accounting from Baylor University and is a certified public accountant.

As CRO, Slayton Gorman will be responsible for all revenue-generation strategy and execution. In this role, he will oversee sales and marketing to ensure those departments work cohesively to execute the company strategy and achieve revenue goals. Mr. Gorman brings more than 20 years of experience in the healthcare industry to Payer Compass. He most recently served as executive vice president of sales and account management for Equian, LLC. He has also held positions with Trover Solutions, Inc. and Optum, a division of United Healthcare. He earned a Bachelor of Science degree in administration and a Bachelor of Science degree in marketing from the University of North Florida.

Payer Compass is an innovative healthcare technology company providing the most trusted healthcare reimbursement technology and price transparency solutions utilizing both proprietary technology and unsurpassed customer service. The company’s core software platform, VISIUM™, is used by a wide variety of customers including health plans, self-insured employer groups, third-party administrators and brokers to manage complex healthcare reimbursement and pricing strategies for Medicare, Medicaid, and Commercial through its proprietary contract management system and claims pricing engine. The company’s single-source reference-based pricing solution, INNOVATE360, consists of not only renowned claim pricing and editing technology, but also the full gamut of provider outreach, patient advocacy and balance bill strategy with appeals support.

June 12, 2019

Understanding Medicare Reimbursement Rates

Want to gain a better understanding of Medicare reimbursement rates? You might have better luck trying to win the lottery.

Given that there is a complex system of different hospitals and physicians to deal with, it’s easy to see why it can be so confusing.

“Medicare reimbursement” is the term used for the payments that hospitals or doctors are given in return for the care they administer to a Medicare beneficiary. The Medicare Reimbursement Rates are set by Medicare, and these rates are usually lower than the amount that is billed, or the amount that the healthcare provider would quote a private insurance company.

What is a Medicare Participating Provider?

A participating provider is any facility or physician who agrees to accept the rates that are set by Medicare. This means they accept the Medicare reimbursements for all services that are covered under Medicare, and anyone who is covered by Medicare can apply for them. The facility or physician bills Medicare directly for the covered services.

One recent analysis of the healthcare market (Kaiser Family Foundation) found that 93% of non-pediatric PCPs were classed as participating providers, though, it’s important to note that only 72% of them were currently accepting new patients covered by Medicare. For this reason, if a patient has a doctor they’re happy with, it’s worth trying to stay on their books.

What About Non-Participating Providers

Matters are further complicated when dealing with non-participating providers. There are a number of healthcare providers who are non-participating providers, and this means they do not accept the current Medicare reimbursement rates. If a patient seeks treatment from a facility or physician who is a non-participating provider, that patient may be asked to pay the bill up front,  then turn to Medicare for reimbursement of the amount normally to be paid. The provider will be paid 95% of the amount that is listed on the fee schedule. Then they are allowed to bill no more than 15 percent of the reimbursement amount. Some states set the limit even lower, at around five percent.

Opt-out providers

Lastly, there are some doctors who will not accept Medicare patients at all. It is estimated that roughly one percent of physicians opt out of Medicare completely. It is common for psychiatrists to do this, but some doctors are doing so as well. A physician who has opted out will not accept Medicare payments and will bill the patient directly. There is no limit to the bill that the provider can charge because they are essentially opting as a private business and the matter of billing is between their patients and themselves.

If you have additional questions about Medical Reimbursement Rates, feel free to contact Payer Compass for answers.


Health Value Award Finalists 2019

Spotlighting outstanding, value-based healthcare services

Portsmouth, N.H. – March 7, 2019 – The Validation Institute is pleased to announce this year’s 85 Health Value Award finalists. In its second year, the Health Value Awards continues to recognize outstanding services, products, and programs across 34 categories spanning the healthcare industry.

“We’re so excited to celebrate our award finalists. Participating in the Health Value Awards shows these healthcare companies and providers are not only committed to providing high-quality, value-based healthcare, but are ready to lead the industry in this new, exciting, and necessary direction,” said RD Whitney, CEO of Validation Institute.

Health Value Award candidates complete a lengthy and rigorous application process, particularly those nominated for validated program categories who participate in an in-depth evaluation to ensure the accuracy of performance claims.

This year’s finalists are:

AABC Birth Center Care
Access HealthNet
Alight Solutions (Compass Healthcare Navigation Solutions)
American Airlines
Anthem Inc. Enhanced Personal Care
b.well Connected Health
Barbados Fertility Centre
Best Money Moves
Boston Heart Diagnostics
Carmel Clay Schools
Christiana Care Health System
City of Kirkland
Comcast NBCUniversal
Concord Management Resources
Connect DME
Connect Healthcare Collaboration
Cubii Compact Elliptical
Dean Foods
Health Rosetta
E Powered Benefits
Eden Health
Edison Healthcare
EmpiRx Health
Employee Benefits Management Services (EBMS)
Epigenix Health
Exclusive Surgeries Solutions, LLC
EZAccess MD
Gallagher Innovation Lab
General Motors
Green Imaging
Group & Pension Administrators
Health Rosetta
IM HealthIndus Health
Integrated Musculoskeletal Care (Primary Care SuperClinic)
Insurance Offices of America
MAP Health Value Based Pricing
MAX HealthPLan Solutions
Medliminal LLC
State of Montana Employee Health Plan
Nabholz Construction
Nova Healthcare Administrators
Nurse – Family Partnership
OneCall Health Solutions
Payer Compass, LLC
Pittsburgh Business Group on Health
Questige Consulting
Reflexion Health
Remedy Analytics
Remedy Partners
Rx Manage
Salt River Pima Maricopa Indian Community
Southern Scripts
The ARC Fertility Program
The Leapfrog Group
The Zero Card
U.S. Preventive Medicine
US HealthCenter PredictiMed
USI Insurance Services
US-Rx Care
VBA Software
Venebio Group
Vera Whole Health
Virginia Mason Health System
Virtual Physical Therapists
VIVIO Health
Washington State Health Care Authority
WellStart Health

Along with validated and non-validated categories, the Validation Institute will also be recognizing individuals who have made enduring and meaningful contributions to the healthcare industry with honorary and lifetime achievement awards.

Winners will be announced live at the Health Value Awards Ceremony at the Wardman Park Hotel in Washington, D.C. on Sunday, April 28, 2019 starting at 5:00 P.M. followed by a short reception.

About the Validation Institute:

The Validation Institute is a membership organization made up of a network of healthcare vendors, health benefits advisors, and purchaser benefit managers focused on delivering better health value and stronger outcomes than conventional healthcare.

If you would like more information about our placement as a finalist, please contact Ginger Barrientez, Director of Marketing at 469.215.2654 or email at

Spectrum Equity Leads Majority Recapitalization of Payer Compass

Plano, Jan. 4, 2019 – Payer Compass, a leading provider of healthcare reimbursement technology and price transparency solutions, announced today that it has received a significant investment from Spectrum Equity, a growth equity firm focused on the information economy, and Health Enterprise Partners (HEP), a healthcare-focused investment firm. This investment positions Payer Compass to continue its rapid growth while further extending its comprehensive product offering serving health plans, self-insured employer groups, third-party administrators and brokers.

Payer Compass’ core software platform VISIUM™ is a purpose-built healthcare pricing engine and contract management system focused on addressing the complexities of Medicare, Medicaid and Commercial claims pricing. With the rise of healthcare costs and shift to self-funded plans, Payer Compass enables employer groups and health plans to realize significant cost savings by utilizing a Medicare-based reimbursement method as it is more closely tied to the true cost of providing care.

“We are extremely proud of the success Payer Compass has achieved to date as we have grown the company to serve over 125 payer customers, representing nearly 1,000 employer groups and over two million covered lives. We are excited to partner with Spectrum and HEP as their experience scaling leading healthcare technology companies will allow us to take advantage of the large market opportunity in front of us in broader healthcare cost containment and price transparency,” said Payer Compass CEO Greg Everett. “We are seeing rapid adoption of our solutions across key markets given the growth of government-sponsored healthcare and reference-based pricing and will continue to see expanding use cases for our unique pricing technology going forward.”

“We are thrilled to partner with Payer Compass as the company continues to scale rapidly and impact more of the cost containment landscape,” said Jeff Haywood, Managing Director at Spectrum Equity. “The company’s proprietary pricing technology and data are highly unique resulting in more accurate pricing, increased auditability and greater provider acceptance.” Steve LeSieur, Managing Director at Spectrum, added, “Payer Compass sits squarely at the intersection of several key investment themes for Spectrum within healthcare as the company’s platform addresses the rising costs of healthcare faced by self-insured employer groups and health plans as well as the fundamental need for greater healthcare price transparency. We look forward to working with Payer Compass management to expand the company’s go-to-market and product efforts to fully capitalize on this growing opportunity.”

As part of this transaction, Jeff Haywood, Steve LeSieur and Michael Radonich from Spectrum Equity, as well as David Tamburri from HEP, will join Payer Compass’ Board of Directors.

If you would like more information about this healthcare initiative, please contact Ginger Barrientez, Director of Marketing at 469.215.2654 or email at

Recapitalization for Our Company and What it Means

Payer Compass is known as a leading provider of healthcare reimbursement technology and and cost containment solutions. Recently, our company received an investment from Spectrum Equity and Health Enterprise Partners through recapitalization.

This investment allows us to continue our rapid growth, while making substantial progress in extending our services to brokers, health plans, third-party administrators, and self-insured employers.

What drove us to recapitalize?

We took this route for several reasons. First, we felt the movement of the competitive landscape and wanted to secure our place as a continued leader.   We’re also set to enhance infrastructure, expand product offerings, and grow our footprint in current and new markets. Additionally, we’ve been in business nearly six years, it’s about time we grow up, at least a little, and build our leadership team, and this will allow us to do so.

When we first considered recapitalization, we had to stop and consider both the mid- and long-term. Recapitalization is beneficial for expansion, something we’ve wanted to do. As funding comes into the picture, it accelerates the company’s progress as a whole. Essentially, Payer Compass is using this opportunity to grow and further bridge the gap between payers and providers, in order to ultimately help more people in need of affordable, quality healthcare. These opportunities wouldn’t be possible without this new partnership.

We want to build a strong company

Our new partners are successful in helping companies like ours integrate the pieces needed to maintain a substantial business, increase value, and construct a solid infrastructure, with the right resources and market strategy.  

We want to fulfill our potential

Though Payer Compass is still in somewhat of a nascent stage, we’ve made a huge, positive impact in the healthcare industry. We are proud to have grown the company to serve over 125 customers, representing nearly 1,000 employer groups, and over 2 million covered people.  We have also grown as an organization from two to 70 team members in under six years. But we don’t want to stop there or simply maintain, we want the ability to scale the business and break barriers that were preventing us from entering specific markets and gaining more opportunities. Our partnership with Spectrum and HEP allows us to continue to invest both in our team and in our assets – new technologies, new companies.

Why did we choose these partners? What do they do?

We took our time and vetted candidates carefully, looking to partner with firms who feel as passionate about healthcare affordability as we do, share our vision for growth, and share the same ideals about corporate culture. In the end, it came down to a feeling – choosing Spectrum Equity and Health Enterprise Partners (HEP) just felt right. Spectrum is a growth equity that provides capital and strategic support. This firm builds great value for market-leading software, information services, and internet companies. HEP invests in private, mid-market companies in healthcare services and health care information technology. HEP strives to improve quality in patient experience, increase accessibility and reduce overall costs of healthcare. Both firms possess extensive experience in scaling leading healthcare technology companies.

In our case, Payer Compass possesses the services and noticeable scale in the cost containment landscape that interests Spectrum. With pricing solutions such as our core platform, VISIUM, which focuses on the complexities of Medicare, Medicaid and Commercial healthcare claims, we  can address the rising costs of healthcare faced by self-insured employer groups and health plans, as well as the fundamental need for greater healthcare transparency. With the support we are receiving from Spectrum and Health Enterprise Partners, we will be able to further impact cost containment innovation.

Recapitalization will not cause our company culture to change

We’ve tried to cultivate a productive, hospitable culture that keeps our team members engaged. And while our recapitalization efforts mean a seismic shift in our business, we didn’t want to disrupt the culture. Our team is like a family, and we respect every individual’s skills, intelligence and uniqueness. Which is why we’re making every effort to maintain the same work environment we’ve always enjoyed.

While still maintaining operational and cultural control of our business, our solutions will continue to be implemented across key markets, as indicated by the growth of government-sponsored healthcare and reference based pricing.

Overall, these partnerships have bolstered the presence of  Payer Compass and are taking us in the right direction, with new strategies and capital for growth.

Finally, we’re excited to welcome Jeff Haywood, Steve LeSieur, and Michael Radonich from Spectrum Equity, along with  David Tamburri from HEP, to the Payer Compass family’s Board of Directors.

If you would like more information about this healthcare initiative, please contact Ginger Barrientez, Director of Marketing at 469.215.2654 or email at

payer compass-spectrum-recapitalization
Spectrum Equity

Best Practices for a Productive Organizational Culture in Healthcare

In a competitive and aggressive industry like healthcare, a productive organizational culture can give you the edge you need over the competition. Creating a pleasant environment where people can (and want to) do their best work is key to achieving a shared vision for the company, where everybody’s on the same page, and shooting for the same goal. Here at Payer Compass, we follow these best practices and we’ve included a few quotes so you can hear from our own team how well these recommendations work.

Here are some ways to improve your organizational culture:

Define your culture

Discuss your company beliefs, values and norms. Culture is more than just, “the way we do things around here.” It helps create the environment your team will work in and organically form a shared focus and vision. Don’t just plaster inspirational words around a board, do something fun and enjoyable for your team members to further engage in understanding why and how the company works the way they do.

“It’s fun. It’s hard work but we enjoy each other’s company and we enjoy working hard together, making a difference in the industry.” -Kellie Jackson, Vice President, Sales & Client Engagement

Hire to fit

Hiring people that fit your culture is key to maintaining it. A good way to do that is to communicate those company beliefs and values we talked about earlier during your interview process. You can’t hire someone with a different attitude towards your culture and expect the tone of the environment to stay the same. For example, your company has an office culture that is relaxed and casual, where everyone supports one another. However, you hired an employee who turns out to be loud, aggressive, and only cares about themselves. This would result in an uncomfortable workplace for everyone, and offset the overall balance that you tried so hard to maintain in your office.

“I like the environment and culture that we have here. I’ve come from a lot of different companies and this one just seems to suit everything that I’m looking for: a work life balance and just having a family. Because the majority of our week we spend it at work, right? This is my second family and this is my second home, I love what we do and I’m all about it.” -Stephanie Nguyen, Senior Account Representative, Client Services

Goal transparency

Set up clear goals for your company to strive to reach. Putting an emphasis on the bigger picture lets your team know there is a vision that everyone is expected to adapt.

“The people here, they care. It’s like a family. Folks are gonna be working hard together to get to the same place, and in a lot of other instances I’ve had to fight to get a solution. I’ve had to struggle to get from point a to point b, when we all know where point b is where we need to go. But here, and while we might not agree all the time, everybody understands the goal, everybody understands where we’re headed, and I think everybody enjoys to be a part of something that’s, at the end of the day, it’s groundbreaking.” -Jeff Winslow, Director of Client Services

Develop a plan for measurable improvement

Developing a key metrics system for improving employee performance is vital to living up to the vision that your goal setting is focused on. Keeping track and seeing progress towards personal and organizational goals is an efficient and effective way for your team to achieve them. This also allows each of your team members to give focus to those key areas that may require improvement.

Create unity

Creating a unified team is something that every company should practice in the workplace. Get to know your team members and encourage them to play to their strengths in order to strategically create a synergized effort when working towards company goals. Making connection between others is a priority in order to achieve a great overall performance and operational success when overcoming obstacles in the industry.

“Working with this [Payer Compass] family, like this team, one of my favorite mottos is, “Teamwork makes the dream work” and it sounds so silly, but I literally love that we’re all a family here and we collaborate and work together and we really make a difference and we do it successfully as a team to make the dream work. That’s what I love about Payer Compass.” -Stephanie Nguyen, Senior Account Representative, Client Services

Give them freedom, fun, and appreciation

It’s time for companies to quit treating employees like robots or second-rate individuals and actually treat them like people. People do not like to be managed to the point that they feel dictated, they know what to do and it would be nice to give them some space to do their work stress-free. Let team members  be self directed, and step in only for group discussions about their progress on company goals. A great idea is to implement a “fun” day of the month in the office, where everyone can engage in fun, yet functional activities. Encourage your team to experiment with new ideas on how things can be done better and have them share their findings during your next group discussion. Lastly, vocalizing your appreciation for your team as a whole and individually will give each one of them a sense of belonging and purpose that will result in loyalty for your company.

“It’s a challenging job, it’s a rewarding job though and it’s great to work with people that you know and like and really care about that you have worked with for a long time.” -Timothy Martin, EVP and General Counsel

Here at Payer Compass, we’re a unified group who practice the principles of commitment, community, communication, and care into every aspect of our work. We are committed to helping others, and work hard for our community by means of communicating effectively with those who care.