An industry-first solution
The Optum® MedicalRx Specialty Provider Network addresses cost variability and helps manage spend in a new way. The Medical Specialty Provider Network consists of medical providers who infuse/inject targeted specialty drugs that are currently paid on the medical benefit. Under the new network terms, contracted providers continue to self-procure and administer medications and then bill Optum for the cost of the medication and administration together using standardized reimbursement rates.
This innovation allows providers to obtain medications where they see fit, leveraging their class of trade discounts, and then be reimbursed at a fair market rate that is confirmed in advance. Optum has created this innovative network to meet the provider's need to buy and bill; additionally, the network creates a mechanism that controls historic site of care variations in cost.
The benefits of this network approach are many. By using standardized reimbursement rates, it eliminates site-of-care cost inflation and variation. Providers enjoy a more predictable reimbursement timeline — up to four weeks faster than the typical medical claims billing process.
Another benefit of the MedicalRx Specialty Provider Network is a consistent member experience. By offering entry to the network to any willing provider, member disruption is mitigated. Moreover, to assist them in locating network providers, the MedicalRx Specialty Provider Network provides concierge services for members.
Above all, this approach delivers savings to clients. The drug Orencia® is a good example of how the MedicalRx Specialty Provider Network saves money. Used to treat rheumatoid arthritis, Orencia costs an average of $5,000. In comparison, the MedicalRx Specialty Provider Network cost for Orencia is $4,250, a savings of $750.
Clients who choose to implement the MedicalRx Specialty Provider Network can expect savings up to 5% on a per member per month (PMPM) basis from this program alone. 2
“The MedicalRx Specialty Provider Network truly exemplifies how Optum Rx is tackling the toughest challenges in health care through innovation,” says Dee Grein, senior vice president, product and strategy, Optum Rx. “For the first time ever, plan sponsors can achieve standardized reimbursement rates for specialty medications billed under the medical benefit and achieve significant savings while mitigating disruption for their members.”