WellRithms Q42016
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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.
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46
32
45 to 65
26
30
Over 65
4
20
More than 53 percent of residents have at least some college education, with just over 29 percent having an associate, bachelor’s, or graduate degree. More than 90 percent of residents have at least a high school diploma.
The average unemployment rate in the county is 9.9 percent:
Market Share Distribution Percentage With a Major Competitor
Five Years Ago
Last Year
Stevens District Hospital
48
35
Competitor
30
43
Out of County Hospitals
22
22
Patient Origin by Zip Code
96101 is Stevens District Hospital zip code
94963 is major competitor hospital zip code
Increases in the percent of population with chronic disea ...
10th Anniversary Webinar Series: The Definitive Guide to Emergency Call Coverage
MD Ranger Chief Strategy Officer Allison Pullins summarizes and reviews the findings from The Definitive Guide to Emergency Call Coverage.
Learn more about ED call coverage, including:
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Learn more about ED call coverage, including:
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Price Transparency
This document discusses the importance of price transparency in healthcare. It notes that the Affordable Care Act requires hospitals to publicly report their prices. With more consumers enrolled in high-deductible health plans, hospitals need to provide price information to engage cost-conscious consumers and avoid losing business to lower-cost alternatives. The document outlines challenges to price transparency like complex pricing structures and a lack of regulations. It provides recommendations for hospitals to establish price transparency, including forming a task force, building a business case, ensuring organizational readiness, and training staff to discuss prices.
Everything You Must Know About Physician Emergency Call Coverage
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Nobilis health corporate presentation march 3.23.18 final[2]
Nobilis Health Corp. is a healthcare company that owns and operates ambulatory surgical centers (ASCs), surgical hospitals, and ancillary services across five states. It has a unique direct-to-consumer marketing model that drives organic patient volume growth. For 2017, Nobilis Health reported $300 million in revenue and $41 million in adjusted EBITDA. The company aims to continue growing organically through marketing and acquiring complementary businesses.
8 RCM Concerns
Revenue Cycle Management in healthcare encompasses the entire administrative process involved in getting paid for the services you provide to your patients. The process begins when a patient first calls to schedule an appointment and ends when all fees have been collected and verified.
Medical billing is becoming increasingly more complex. It is only going to get more difficult as new codes are added and more detailed patient information is required to be submitted with the claim. Add to that, physicians and other service providers are required by various insurers to provide details not previously necessary.
One small error can result in the claim not being paid promptly, completely or possibly even being denied.
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NYU Langone Medical Center’s TJA BPCI Experience: Lessons in How to Maximize ...
The Bundled Payments for Care Improvement (BPCI) Initiative began generating data in January of 2013. Dr. Iorio will outline the challenges and benefits of implementing BPCI for Total Joint Arthroplasty at an urban, tertiary, academic medical center with a hybrid compensation model. Early results from the implementation of a Medicare BPCI Model 2 primary TJA program demonstrate cost-savings with an improvement in quality of care metrics and continued cost savings through year 3 of our experience. Changes in patient optimization, care coordination, clinical care pathways, and evidence-based protocols are the key to improving the quality metrics and cost effectiveness within the implementation of the Bundled Payment for Care Initiative, thus bringing increased value to our TJA patients.
Maximizing Value in a Bundled Environment – Keys to Success:
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Richard Iorio, MD, is the William and Susan Jaffe Professor of Orthopaedic Surgery at New York University Langone Medical Center Hospital for Joint Diseases and Chief of Adult Reconstruction at NYU Langone HJD. He co-founded Labrador Healthcare Consulting Services, Responsive Risk Solutions, and the Value Based Healthcare Consortium in 2015. He is a member of the Board of Directors for LIMA, the Lifetime Initiative for the Management of Arthritis. Dr. Iorio is a national expert in physician and hospital quality and safety and a leader in the implementation of alternate payment paradigms in orthopaedic surgery.
Physician Contracting Best Practices for Health Systems
This webinar is geared towards health systems and those working with health systems who want to gain efficiencies within physician contracting and learn how to structure internal guidelines and processes.
During this webinar, you will:
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--Review studies of MD Ranger subscribers
Edifecs: Demonstrating who you are in CJR
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If your facility could use best practices for determining and documenting FMV for physician contracts, join us for our 30-minute webinar covering:
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The Provider Crossroads to Value-Based Reimbursement
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WellRithms Q42016
- 1. A Different Approach to Claim Review info@wellrithms.com 877.886.3268www.wellrithms.com
- 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%