Reference-based pricing

6 Degrees Health offers reference-based pricing alongside healthcare transparency and payment-integrity services for self-funded plans and their administrators.

90 Degree Benefits is a national third-party administrator with more than 23 local offices that administers self-funded and level-funded employer health plans, along with FSA, HSA, ICHRA and consumer-driven plan administration. Its network capabilities include reference-based pricing as an option alongside traditional networks. Its CareConnect program provides member advocacy and navigation, including negotiating rates and facility pricing on members' behalf.

AMPS provides claim repricing, reference-based pricing and payment integrity services to self-funded employer plans, brokers, TPAs and health plans. PriceDynamix reprices medical claims against cost and benchmark data rather than negotiated network discounts, while ClaimInsight performs claims editing and medical bill review; Drexi provides pharmacy benefit management. Members receive care navigation before high-cost elective procedures and continuous advocacy through the balance bill process, with AMPS negotiators handling balance bills on the plan's behalf.

Allied National sells self-funded and level-funded health plans to small and midsize employers through agents, including its Funding Advantage program, with prescription, lab, telehealth, dental and direct primary care components. Its HealthChoices program routes members to designated providers and bundled outpatient surgery pricing, with reduced benefits if members do not pre-notify or use the program. Members are supported by the Allied HealthCare Assistant advocacy line for finding care and navigating complex services.

Aplos Health Plans sells an employer health benefits package built around zero-copay, zero-deductible member cost sharing, combining integrated direct primary care with medical benefits and pharmacy in a single member app. Care is delivered and coordinated through partner clinical teams, with same-day primary care, virtual care, 24/7 urgent care and a medical navigation team that guides members to providers and handles billing questions. The program is marketed as available in all 50 states.

ClaimDOC provides reference-based pricing with appeal and balance-bill handling, litigation defense and support, and a companion stop-loss offering for self-funded employers.

Claritev, formerly MultiPlan, sells Data iSight to health plans, TPAs and self-funded plans as a reference-based reimbursement recommendation engine for out-of-network claims. Recommendations are generally cost-based for facilities and benchmark-based for professional providers, built from publicly available claims data with national benchmarking, regional wage indexing and geographic adjustment. Data iSight includes an integrated appeal-management service intended to resolve provider disputes and limit balance billing, with reported provider acceptance above 90%.

Cypress Benefit Administrators was an independent third-party administrator for self-funded employers, known for pairing plan administration with cost-containment strategies including reference-based pricing. The business is now part of Lucent Health, and cypressbenefit.com redirects to Lucent Health's Cypress page. Employers evaluating Cypress today are administered and serviced under Lucent Health.

ELAP Services was a reference-based pricing vendor for self-funded employer plans that priced facility claims on an audited cost-plus basis rather than against network contracts, and provided members with advocacy and legal defense against balance bills. The ELAP brand is now part of Imagine360, and the elapservices.com domain resolves to Imagine360's employer reference-based pricing pages. Employers evaluating ELAP today are quoted through Imagine360.

H.H.C. Group provides claims negotiation, repricing and medical bill review to self-funded employer plans, TPAs and payers, including a Medicare reference-based pricing service that sets allowed amounts from Medicare benchmarks. Its approach combines attorney-led negotiation with PPO network repricing, line-item bill review, claims editing and auditing, and it also performs independent medical reviews. The firm is URAC accredited and focuses on high-cost and disputed claims.

Homestead Smart Health Plans builds self-funded employer health plans around its own reference-based pricing platform, Claim Watcher, which reprices facility claims instead of relying on network discounts. Homestead owns the pricer, the administration and its own stop-loss company, and offers the plan as full RBP replacement or wrapped with a physician network or direct primary care. A premium tier with regional health-system partnerships is available in New Jersey, New York and Pennsylvania.

HST's reference-based pricing business is now sold by Claritev under the Vistara brand and prices facility claims using Medicare as the starting benchmark while routing professional claims through the PHCS network, producing a hybrid RBP/PPO plan design for self-funded employers. Claritev publishes an average medical claim discount of 75.6% and a 99% provider acceptance rate for the program. Members are supported by a Patient Advocacy Center for billing questions and by a mobile app that compares providers on cost, quality and likelihood of accepting the plan's rate.

Imagine360 combines third-party administration, member advocacy and reference-based pricing in one self-funded plan solution, pricing facility claims off Medicare and reported cost data and resolving balance bills through its member advocate team.

Lucent Health is a national third-party administrator for self-funded employers that combines plan administration, care management, concierge member navigation and pharmacy benefits, and describes itself as one of the largest administrators of reference-based pricing plans. It supports configurable single- and dual-network plan designs and provides provider contracting and balance-billing assistance for members. The company states employers typically save about 25-30% in the first year with subsequent trend under 3%.

Marpai is a third-party administrator for self-funded employers offering plan administration, compliance, analytics and plan design, together with reference-based pricing and non-network options delivered through direct contracting. Its end-to-end claims repricing service is marketed as saving up to 60% on out-of-network claims, and the company operates its own pharmacy benefit manager, MarpaiRx. Member support includes proactive outreach, a provider shopping tool, gaps-in-care outreach and clinical oversight.

Nova Healthcare Administrators is a third-party administrator serving self-funded employers with medical plan administration, consumer account administration (HSA, FSA, HRA), dental and vision administration, care management and white-labeled business process outsourcing for other payers. It positions itself as an advisor to plan sponsors rather than a transactional administrator, and its service representatives support members with billing questions and case management. Reference-based pricing is not published as a named Nova product.

OccuNet's Fairos program reprices facility claims to an effective Medicare multiple and backs it with a large base of direct provider agreements, so most claims settle without a balance bill. It is the RBP engine inside several level-funded programs.

Payer Compass provided reference-based pricing and claim repricing to self-funded employer plans, TPAs and payers through its Visium platform, pricing claims against Medicare-based and other public benchmarks rather than network contracts. The business is now part of Zelis, and payercompass.com redirects to Zelis, where the capability is sold within the Zelis Intelligent Pricing Platform alongside Zelis reference-based pricing and payment integrity services.

Roundstone places small and midsize employers into a group medical captive so they can self-fund with pooled stop-loss risk, refunding 100% of unused premium to the employer. The model emphasizes claims data access and transparency for the employer, with guaranteed savings language and a stated average total annual cost roughly 25% below industry averages. Reference-based pricing is not published as a named Roundstone product; cost-containment components are configured through the plan's administrator.

The Phia Group supports self-funded employer plans and TPAs with plan document drafting, compliance and fiduciary services, subrogation and recovery, and cost-containment products. Its Phia Unwrapped service reprices out-of-network claims and handles No Surprises Act workflows, while Care Empowered Pricing is its reference-based pricing offering; both are paired with provider negotiation and balance-bill resolution. PACE provides independent claim appeal evaluation, and the firm defends plan participants against unexpected provider bills.

Trustmark Health Benefits administers self-funded health benefit plans for employers, marketed to businesses with five or more employees and positioned as bringing large-group plan capabilities to smaller groups. Plan design, network selection and cost-containment components are configured per employer through its third-party administration services. Reference-based pricing terms, member advocacy details and balance-bill support are not described on its public pages.

Valenz reprices out-of-network claims using multiple data sources rather than a single Medicare multiple, and pairs repricing with its owned high-performance networks in select states. It guarantees financial responsibility on repriced claims.

Vitori Health sells health plan solutions to self-funded employers that combine PPO network options, reference-based pricing options, stop-loss integration and member support in a single package. The company markets a Claims Savings Guarantee, backed by the Vitori Victory Guarantee, under which it reimburses an employer up to $1,000,000 if contracted savings targets are not met. Members receive advocacy and high-touch service alongside the plan's payment strategy.

WellNet Healthcare sells self-funded and level-funded health plans to employers with integrated administration, claims analytics and cost management, using a phased 'crawl, walk, run' toolkit of more than 20 cost-containment components. Its payment strategy includes billing error correction and balance bill defense alongside carve-outs for dialysis, advanced imaging and direct primary care, plus a pharmacy strategy that can include international sourcing. Members are supported by personal healthcare concierge teams.

Zelis sells claims pricing and payment integrity services to health plans, TPAs and self-funded employer plans, including a reference-based pricing product that caps allowed amounts against public benchmarks instead of relying on network discounts. These capabilities are delivered through the Zelis Intelligent Pricing Platform, which combines payment integrity editing with claims pricing. Zelis sells primarily to payers and administrators rather than directly to employers, and now includes the former Payer Compass business.