Resource Center // Blog // HealthSmart Blog // November 2021

SmartDecision's Member-Centric Approach Delivers Greater Value Through Reference-Based Pricing 

11/9/2021 2:46:17 PM

SmartDecision's Member-Centric Approach Delivers Greater Value Through Reference-Based Pricing 

By Craig Julien, executive vice president of TPA operations

As an innovative industry leader, HealthSmart has a successful track record of helping self-funded health plans lower costs, maintain and improve quality outcomes, and enhance member satisfaction. Our SmartDecision Reference Based Pricing (RBP) Solution has been a foundational component of our approach to helping clients achieve these goals. Our multi-faceted solution includes a reference-based pricing administration, outpatient bundled payments, physician and ancillary PPO networks, SmartDecision has historically delivered overall savings of more than 60 to 70 percent off hospital and facility billed charges. 

SmartDecision emphasizes proactive collaboration among all parties involved in planning, delivering, and paying for care. The result is greater transparency into the process, enabling members to make more informed decisions about who will provide their care, where they will receive care, and their financial liability for that care. SmartDecision enables members to take charge of their care by fully informing them of their coverage, their options, and the financial liability of their decisions.

Now SmartDecision is even better.

HealthSmart’s proprietary services make SmartDecision the best way to support members in getting the right care at the right price at the right time:

•    Our SmartDecision Concierge offers members a high-touch, single point of contact for all service and benefit questions, directing them to the most cost-effective, high quality providers. Simultaneously, concierge specialists work directly with providers to confirm reimbursement amounts in advance and answer their questions. This approach results in fewer disputed claims and incidents of balance billing of members after the episode of care.
•    Our Care Management team are experts at managing populations with unique risk profiles or severe, rare or chronic conditions. The goal of care management is to reduce costs, improve the health and productivity of members, improve member morale by enhancing their engagement in improving their overall wellbeing, thereby improving clinical outcomes.
•    Our comprehensive HealthSmartRx Solutions High Cost Drug Management approach provides access to preferred retail chain networks and the most cost-effective pharmacy plans available. Health plans and members benefit from: 
  • a significant reduction in drug spending, 
  • an increased focus on generic drug utilization where clinically appropriate, 
  • 24-hour access to eligibility information, claims history and forms through a member portal, 
  • a focus on directing member treatment to the appropriate site of care,  
  • access to skilled pharmacy technicians focused on improving medication adherence, 
  • and significant savings on total specialty medication spending.
•    Our bundled payment program, which is available in several markets, leverages our high-quality, lower cost Preferred PPO Network for all-inclusive pricing on non-emergency elective procedures including orthopedic, general surgery, spinal and neurological, women’s health, advanced imaging, endoscopic procedures, and more. On average, this program delivers 30 to 40 percent incremental savings for elective procedures over what traditional PPO networks offer. Our clients enjoy reductions of four to seven percent on their overall medical claim spend using this approach.

Recently, we’ve partnered with industry leader HST to provide the backbone of the RBP administration. HST’s approach has a demonstrated 98 percent acceptance rate by providers, reducing billing concerns and reassuring clients that members will have a satisfactory experience of care. 

The new SmartDecision not only encompasses hospitals and facility fees,  it also includes physicians and ancillary services. 

Learn more about SmartDecision by viewing our recent webinar, which can be found here. To see if SmartDecision is the right choice for your clients, contact

About the Author

Craig Julien joined HealthSmart in 2016 as Senior Vice President of Operations for the Company’s eastern region. In 2018, he was promoted to Executive Vice President, TPA Operations, overseeing HealthSmart's core operational and service functions for medical, dental, vision, COBRA, FSA and STD claims administration.
Prior to joining HealthSmart, Craig served as Vice President of Global Operations for TriZetto, a Cognizant Company, where he was responsible for all aspects of claims operations, including receipt and entry of membership data, plan building, account management, inventory management, claims processing and customer service. He has 20 years’ experience in BPO operations, 10 years’ experience in the healthcare payer vertical and eight years' experience with the QNXT and QicLink platforms. Prior to his experience at TriZetto, Craig held senior level roles with Kenexa Technologies (an IBM Company), Ceridian, and CNA Insurance Companies.

Craig holds an MBA from University of California – Irvine, a BS in Business Administration from University of Phoenix, and a number of certifications, including a Six Sigma Green Belt.