About Sustainable Claim Pricing

Out-of-network claims introduce some of the highest variability and risk in group health reimbursement.

Without contracted rates to anchor payment, reimbursement decisions are often driven by billed charges, arbitrary percentages, or negotiated assumptions. These approaches can produce short-term reductions, but frequently collapse under scrutiny when providers challenge payment.

Sustainable Claims Pricing (SCP) exists to bring accuracy and consistency to out-of-network reimbursement. By analyzing medical bills and claims at the line level and applying a cost-based, data-driven pricing methodology, SCP ensures reimbursement recommendations reflect what care should reasonably cost, not what was billed.

Core Components

• Line-Level Medical Bill And Claim Review: Each out-of-network medical bill or claim is reviewed charge by charge to ensure accuracy and consistency.
• Cost-Based Pricing Methodology: Reimbursement recommendations are established using validated cost data rather than percentage-based reductions or negotiated targets.

Why Sustainable Pricing Matters

Out-of-network reimbursement decisions are rarely final when first issued. They are examined, challenged, and revisited.

SCP replaces assumption-driven pricing with line-level accuracy. Recommendations are grounded in actual bill detail and validated against real underlying cost data, allowing them to remain consistent when examined by providers seeking full reimbursement.

When applied correctly, this approach produces meaningful financial impact, with average reductions of approximately 72% off billed charges observed across eligible out-of-network medical bills and claims. More importantly, those recommendations hold because they reflect reality, not negotiation.

• Application Across Claim Types: SCP applies to inpatient, outpatient, professional, emergency, ambulance, and ancillary services.
• Defensible Reimbursement Recommendations: Recommendations are documented clearly and structured to remain consistent when examined by providers, consultants, or legal teams.

Let’s Take A Look

Start with a single out-of-network medical bill or claim.

Whether you’re addressing a catastrophic case or evaluating historic claims, SCP can help clarify what should have been reimbursed and why.