• How does VBP work?

    Most health plans rely on a PPO network. In this model, the PPO negotiates a contract with a facility and any claims incurred are paid based on that contract.

    In a VBP plan, Facility claims are repriced based on a percentage of Medicare payment. This results in a lowered cost of care for everyone involved. For procedures performed in a facility, this begins during the pre-certification process. The plan requires pre-approval for these procedures by calling into a Utilization Review organization. When this occurs the plan also provides an estimate of payment to the facility. Once the procedure has been performed, the plan pays based on that estimate as well as any other charges incurred during the course of the procedure just like a normal plan.

    Because these claims are paid outside of a contract, there is a chance the provider will dispute the payment amount, and potentially balance bill the member. In these cases the member will be referred to the Patient Advocacy Center or PAC. Once notified the PAC begins negotiation on behalf of the member. The PAC will contact the facility on behalf of the plan and come to an agreement on rate. This process can take time, so while these negotiations are ongoing the PAC will continue to provide updates to the member.

  • What providers can I see, what facilities can I go to for treatment?

    You have access to a provider only network. This network operates the same as any PPO network, however is comprised entirely of physicians. There is no contract with facilities.

    You can also go out of network, but you may be subject to out of network (OON) costs based on how your employer chooses to structure your plan. OON provider claims will also be repriced using a calculation based on a percentage of Medicare.

  • My provider said that I had to pay up front before they would see/treat me. What do I do?

    Contact the number on your card. Lucent can assist you in working with the provider, or finding another provider who does not require up-front payment.

  • I’m still getting bills from my provider/facility, can Lucent help me understand what I should pay and what my employer pays?

    Contact the number on your Card. Lucent can help you understand your plan and benefits.

  • I just had a visit and I’m still confused about my payment process, treatment plan, and next steps. Who can I talk to?

    Contact the number on your Card. Lucent can help you understand your plan and benefits.

  • When should I seek pre-certification for care? Where do I submit the necessary information?

    There is a list of procedures requiring pre-certification provided in your Summary Plan Description. Providers should be aware of this list, how to obtain details on procedures requiring pre-cert, and what information needs to be provided.

  • How is VBP different from traditional insurance networks?

    VBP networks do not rely on pre-negotiated rates. Instead, a Value Based Plan relies on reimbursements based on a percentage of Medicare rates. These payments are estimated for the provider during the pre-certification procedure, and agreed to based on language on the pre-certification letter, ID card, and the Explanation of Benefits (EOB) that accompanies payment.

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