This document describes WellRithms' approach to claim review and summarizes their solution. It notes that while costs for hospitals and physicians have increased mildly in recent years, the amounts they charge have inflated much more. WellRithms develops a defensible market rate for reimbursements by analyzing cost, billed, and Medicare data specific to a geographic area in a transparent methodology. This approach results in significant savings for self-funded plans of 3% average appeal rate and savings ranging from 55-73% across different claim types, with inpatient hospital claims making up the largest portion. Examples show savings of 47-179% on individual claims compared to standard reimbursements.

1. A Different Approach to Claim
Review
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2. ADDRESSING A MARKET NEED
• When looking at the 10 year period of
2004 through 2014, the cost of doing
business for hospitals and physicians
have experienced mild inflation,
4.66% and 1.98% annually.
• However the amounts those same
hospitals and physicians charge for
their services have inflated at a much
higher rate over the same period,
31.5% and 8.09% annually.
• When payer reimbursement
decisions are based solely on billed
charges, which are subject to
accelerated inflation, health care
costs are not contained.

3. THE WELLRITHMS SOLUTION
Methodologies in the marketplace
vary, but leave much to be desired:
• Billed Percentile (FairHealth)
• Problem: Allows egregious
inflation to drive rates.
• Medicare & Cost Based
Multiples (ELAP)
• Problem: Inconsistent
reimbursements, lack of
defensibility, and significant
disruption.
The WellRithms Difference:
• Pulls the required amount of data
for the services and providers in
a geographic area specific to the
location of services.
• Accounts for cost, billed, and
Medicare and group health
reimbursement.
• Establishes a defensible and
non-disruptive market rate by
weighting these elements based
on a consistent, transparent
methodology.

4. SIGNIFICANT SAVINGS WITH
MINIMAL DISRUPTION
• WellRithms was devised by the minds behind Qmedtrix, an industry leader in specialty bill review for
workers’ compensation insurance companies. With 20 years of experience analyzing claim data and
devising reimbursement methodology, when it came time to address the needs of self-funded plans this
was the experience and recognition necessary to get the job done.
• The history and pedigree backing WellRithms has allowed for great success and minimal
disruption in the marketplace. The results have been telling…
• Since 2014, our overall appeal rate is a mere 3%.
• Providers know us, know our methodology, and most importantly
know we recommend fair and accurate payments on claims.
• Our goal is not to disrupt services. WellRithms’ goal is to
achieve fair payments for all parties, and allow self-funded
plans to continue caring for their insured.

5. THE SAVINGS WE ACHIEVEOverall Percent of Savings by Claim
Type
ASC OPH IPH ER PRO
73%
55%
61%
71%73%
• Ambulatory Surgery Centers
• Outpatient Hospital
• Inpatient Hospital
• ER
• Professional

6. THE SAVINGS WE ACHIEVE
Percentage of Total
Savings
2%4%
17%
20%
57%
ASC OPH IPH ER
PRO
• Ambulatory Surgery Centers
• Outpatient Hospital
• Inpatient Hospital
• ER
• Professional

7. SURGICAL CLAIM (PARTIAL ROTATOR CUFF REPAIR)
BILLED CHARGES: $20,750.00
Plan Sponsor Employee Disallowed
WellRithms Increased Plan Sponsor Savings by 47%

8. SUBSTANCE ABUSE REHABILITATION CLAIM
BILLED CHARGES: $16,800.00
Plan Sponsor Employee Disallowed
WellRithms Increased Plan Sponsor Savings by 179%