So You Want to RBP?

How to survive month one and thrive by renewal.

There’s a certain bravado that surfaces when folks first discover reference-based pricing. I remember learning about it a decade ago and thinking, ‘Wait, you can do that?!‘

Slap in one of the ten-plus repricers now out there, enlist your favorite TPA, and watch the savings roll in! Ha. If it were only so easy.

As they say in the South, ‘bless your heart.’

Never forget that RBP is the single most powerful tool available to rein in runaway healthcare costs. When we employ it, we cut facility claims in half and eliminate health insurer involvement entirely. So, yeah, they really don’t tend to love it, and I was reminded of this on Tuesday when I found myself triaging a dozen moving parts before lunch.

We manage numerous RBP plans nationwide. We have a wickedly sharp internal team, aggressive partners, and a long track record of making this work for real employers - people who cut checks and carry risk. And still, a “typical” busy morning looked like this:

• The owner’s grandbaby is due next week, and Mom and Dad do not need a single balance bill showing up in the bassinet. Not one.

• A CEO’s daughter-in-law insists on her chosen OB/GYN, who doesn’t understand RBP and is wary of anything that doesn’t smell like a national PPO.

• HR at Company X is teetering on the ledge over a balance-bill to a particularly cantankerous employee. That employee is convinced collections are coming for his car.

• Company Y is losing its cool over a $15,000 bump in TPA admin expenses to move from a PPO to RBP.

• Company W is wrestling with a $60,000 early-termination fee with a prior vendor. They want to know if they should pay it, fight it, or frame it as a badge of honor.

• My TPA and RBP repricer are grappling over fee language. Both are valuable; neither is wrong, but neither is calming the situation or my team’s nerves.

• Another TPA is frustrated because RBP reduces the revenue they used to count on from negotiated out-of-network PPO “savings” agreements.

• A large claim is stuck moving from a legacy system to the current TPA; everyone wants it paid the day before yesterday and perfectly defended tomorrow.

• A scheduled procedure at Hospital Z, one famous for fighting RBP, must happen today. No delays, no pre-pay shake-downs in the lobby.

• We’re replacing a concierge/care-navigation vendor and need the new team live, trained, and handling member calls without a single dropped ball.

That’s before my afternoon emails.

If you’re still thinking “any broker, any TPA, any repricer,” re-read that list. None of those tasks is exotic to RBP veterans; all of them are landmines to dabblers.

RBP isn’t a toggle to the easy button. It’s an entirely new operating system. It changes incentives, processes, and psychology. It’s a direct assault on the two most powerful stakeholders in the largest segment of America’s economy (healthcare): insurers and hospital chains. It works when you do it right, and it blows up when you wing it.

What Days Like This Teach

1) Member protection as a mantra.
You need airtight member-advocacy, pre-service facilitation, facility outreach, and legally-backed balance-bill defense. People remember how you handled them on their worst or scariest day.

2) Access is earned, not assumed.
The daughter-in-law’s OB/GYN doesn’t dislike your plan; they dislike uncertainty. That’s solved with pre-service calls, clear single-case agreements when necessary, and a payment promise that makes sense. RBP doesn’t mean you can’t work with the providers members want. Instead, it means that in some cases you have to do the work up front.

3) HR’s panic is rational, until you teach them otherwise.
Balance-bill letters look scary. Show HR what’s noise, what’s signal, and how your defense process works. Summarize the flow: who calls whom, when, with what script, and how it resolves. Panic fades when the path is visible.

4) Admin fees go up because the work gets real.
RBP shifts effort from rubber-stamping PPO discounts to actual claim review, outreach, defense, and negotiation. That takes human time and better tools. Yes, you’ll pay more in admin. You’ll pay far less in facility claims. That’s the trade we strive for in our plans.

5) Early-termination fees are negotiable, and so is your backbone.
Sometimes the answer is: we won’t pay an excessive fee for inadequate performance. Other times, you settle for a fraction and move on. What you don’t do is flinch at the first letterhead you receive. Providers and brokers are loath to sue clients for early termination fees, especially when those clients start to illuminate all of the ways the former service provider or broker let them down with poor service or management.

6) Vendor friction is normal; unresolved friction is optional.
Like Michael Jordan’s Chicago Bulls, RBP runs a triangle defense: TPA, repricer/defense partner, and care navigation. Misaligned comp models or fuzzy scopes create sparks. Your job is to align incentives, codify handoffs, and kill ambiguity.

7) Culture change hurts before it helps.
Teams used to PPO economics feel like RBP took away their toys. Help them see the mission: pay fair, fast, defensible rates and protect members. Celebrate wins that used to be invisible under the entrenched regimes’ faux “discount” math.

8) Hostile facilities respect preparation.
Hospital Z will still saber-rattle. But when you walk in with policy language, pre-service documentation, a single point of contact, and a clean payment promise, posturing often yields to scheduling.

9) Tech that isn’t field-tested will crush morale.
Every “integration” sounds great in a deck. The only integration that matters is the one that pays, posts, and defends a claim without manual heroics.

10) Navigation is oxygen.
Members need one number to call. Not a phone tree. Not a committee. One number that answers, explains, and solves. If you don’t own that moment, someone else will, and you won’t like their solution.

What It Takes to Do RBP Well

• A real plan document. Tight SPD language: payment methodology, appeal rights, balance-bill defense, dispute resolution. No boilerplate blather.

• Pre-service choreography. Scripts for schedulers, templates for single-case agreements, and a playbook for “this provider won’t play ball.”

• Member-first defense. A defense partner that answers the phone, coaches the member, engages the provider, and closes the loop.

• Aligned vendors. Clear scopes, Service Level Agreements, and economics ensure that the TPA, repricer/defense, and navigation aren’t tripping over each other.

• Data discipline. claim feeds that run on schedule, meet specifications, and undergo sanity checks. If you can’t reconcile it, you can’t defend it.

• Leadership spine. When a facility tests your resolve or a legacy vendor waves a scary letter, your team needs to see you stand up straight.

• Expectation setting. Tell CFOs the truth: TPA fees will cost more, noise will spike early, savings accrue, and member experience improves as the muscle memory develops.

• Reps and sets. The first 120 days are a workout. Somewhere between days 180 and 270, the noise drops. By renewal, the numbers speak for themselves. And if we must adapt to a particularly irritable hospital system, we can enter into a direct contract with them or add a PPO network back in as an option for solving that access challenge.

The Part No One Puts in the Brochure

RBP brings a gun to a gunfight. Legally, it’s ruthlessly powerful, and judges and juries ultimately never uphold a monopolistic hospital’s claim that they need 300% of Medicare or 600% of costs just to keep the lights on. It’s the mandate for an even playing field in a system addicted to cartel-like pricing.

That makes you, the plan sponsor and consultant implementing it, the adults in the room. Adults do unglamorous things: they read contracts, return calls, document conversations, and show up at 7:00 a.m. to make sure a delivery room doesn’t become a collections seminar. If that sounds exhausting, pick a PPO and enjoy your “discounts.” If it sounds like fiduciary duty, welcome aboard.

On my “typical” day, none of the problems are fatal. All of them are solvable if you have the team, the plan, the vendors, and the will. The savings are real. The member stories get better. And the employers who stick with it stop asking whether RBP “works” and start asking where else they can apply the same level of discipline.

So, do you still want to run an RBP plan? Good. Bring a notebook, a spine, and people who know what they’re doing.

We’ll take it from there.