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    Case Study: Leveling the Playing Field
    Commercial – Network-Based, Analytics-BasedTo improve competitiveness, a regional provider-owned health plan needed assistance with:
    • Extending network access for its highly mobile membership
    • Containing out-of-network medical cost
    • Preserving its relationships and reputation with the local provider community
    Commercial – Network-Based, Analytics-BasedMultiPlan structured a program combining national network access and provider-mindful reference-based pricing:
    • PHCS Network accessed selectively within the provider system’s service area
    • PHCS Network accessed nationally, outside the provider system’s home state
    • Data iSight pricing for claims not contracted by the system or MultiPlan
    Commercial – Network-Based, Analytics-BasedMultiPlan helped the system improve its competitive position while continuing to keep community at its core:
    • Savings generated on 98% of charges submitted
    • 65% of savings with plan member protections
    • 67% average reduction on claims not covered by networks
    • 99% provider acceptance of reference-based pricing results
The PHCS Network: a National NCQA-Accredited Network

MultiPlan's PHCS Network is the only independently-contracted primary PPO network to have been Accredited by NCQA for credentialing – a status we’ve held continuously since 2001. PHCS Network is available in a variety of configurations including outside the plan service area, to extend local HMO or PPO coverage nationally.

NCQA has reviewed and Accredited the PHCS Network’s Credentialing functions only. For complete details on the scope of this review, visit www.ncqa.org

    Case Study: Extending the Power of Bill Review
    Property and Casualty – Payment IntegrityMultiPlan analysis showed a property and casualty servicer how it could strengthen its bill review and network services by:
    • Using analytics tuned to find wasteful or abusive medical billing practices not identifiable by more automated bill review programs
    • Implementing resolution strategies appropriate for the severity of issues and nature of the provider relationships
    Property and Casualty – Payment IntegrityMultiPlan is enabling a comprehensive payment integrity program to complement existing bill review:
    • In place: Clinical Negotiation – clinically-driven negotiation of non-contracted bills scoring high for potential waste or abuse
    • In process: Bill Correction – identification and denial of charges in error, for both contracted and non-contracted bills with evidence of issues missed by the primary editing process
    Property and Casualty — Payment IntegrityFrom the program’s start, MultiPlan Clinical Negotiation has generated significant additional medical cost reduction:
    • Identifying issues on 14% of charges billed
    • Achieving provider buy-in on 47% of charges negotiated
    • Passing the $1 million mark for reduction below bill review allowed, within the first five months
Clinical Negotiation in Action

A spinal fusion procedure billed at $42,452 was reduced by bill review to $24,956. Payment integrity analysis determined that a spinal fusion and lumbar laminectomy were separately billed. Citing CPT Assistant, American Association of Neurosurgeons and the NCCI manual, the lumbar laminectomy is included in the spinal fusion if performed at the same spinal level, and is only as extensive as necessary to prepare the site for the fusion.

After discussion with the provider, the bill was reduced, with provider signoff, by an additional $5,852.

    Case Study: Strategic Negotiations
    Commercial – Analytics-BasedA large carrier offering plans with an aggressive Medicare-based benefit limit sought:
    • To satisfy clients seeking greater protections from balance billing for their plan members
    • To preserve the underlying cost benefits of the out-of-network reimbursement methodology
    Commercial – Analytics-BasedMultiPlan established negotiation parameters that deliver value to satisfy both payers and providers:
    • An upper limit strategically set above the benefit limit, reflecting the value of the agreement to the plan member
    • Use of the benefit limit as a floor, to quantify the benefits of agreement for the provider’s practice
    Commercial – Analytics-BasedMultiPlan delivers negotiated agreements with greater transparency and value for all parties:
    • A 15 point increase in savings rate
    • A less than two point reduction in success rate
Negotiation by the NumbersOver $5.4 billion reduced annuallyDelivering savings with member protections on more than 3.6 million out-of-network claims/bills
    Case Study: Meeting a Specific Need Quickly
    Government – Network-BasedA full-risk plan looking to expand into adjacent counties needed:
    • Assistance with provider network access to meet a looming filing deadline
    • Selective access to providers post-filing, as needed to meet network adequacy requirements
    Government – Network-BasedMultiPlan analysis identified providers under contract that could:
    • Add immediate value for the filing process by filling gaps in the plan’s network
    • Be accessed on an ongoing basis or until the plan could complete contracting efforts
    Government – Network-BasedMultiPlan contributed nearly 700 Medicare providers to the filing and credentialed 20% of the providers to enable ongoing access, helping the plan to:
    • Meet its adequacy requirements for plan-to-plan contracts
    • Successfully apply for a CMS contract in two of the counties
MultiPlan's ability to quickly deliver Medicare-contracted provider access was instrumental to our plan serving our members. Their network also helped us to receive approval to expand into nearby counties. Our account manager was fantastic. MultiPlan's turnaround from discussion to contract execution was really fast, and they worked diligently to meet our budget constraints as well. They are a class act.

CEO, Medicare Advantage plan

 

    Case Study: Fixing vs. Paying Improper Charges
    Commercial – Payment IntegrityMultiPlan analysis uncovered opportunities for a third-party administrator using a variety of PPO networks to:
    • Improve payment accuracy – too much was being missed in the existing editing process
    • Gain control over clinical billing waste and abuse
    • Minimize provider abrasion to preserve leased network relationships
    Commercial – Payment IntegrityMultiPlan implemented a provider-mindful payment integrity process that balances action with evidence:
    • Claim Correction service to catch errors missed by the primary editor
    • Audit Alert service to enable targeted examination of medical records pre- or post-payment
    Commercial – Payment IntegrityMultiPlan’s payment integrity program helps the TPA to deliver greater accuracy and lower medical cost without undue provider pushback:
    • Additional 1% medical cost reduction from claim correction
    • Less than 1% of corrected claims lead to provider appeal
    • Nearly 1% of paid dollars flagged for audit due to more complex errors
Believe It or Not: What Our Payment Integrity Services Find
Excessive Services

49 hours of critical care time ...

billed for a single day.

Unlikely Procedures

Smoking cessation counseling services ...

billed for a four-year old patient.

Suspect Patient Patterns

Patient visits ER for a dislocated shoulder ...

at 10 different hospitals in 2 months.

    Case Study: Partnering to Achieve Certification
    Property and Casualty – Network-BasedA workers’ comp services provider needed help maintaining State Certified Managed Care programs by:
    • Eliminating provider coverage gaps in geographies not addressed by its proprietary network
    • Strengthening coverage for key medical specialties
    Property and Casualty – Network-BasedMultiPlan customized a process to meet network access and mandated reporting requirements:
    • MultiPlan Workers’ Compensation Network – adds access to 2,200 additional hospitals and over half a million other providers
    • Customized reporting to assist in maintaining state-specific provider demographic data
    Property and Casualty – Network-BasedMultiPlan helped the company maintain certification in three markets, together with:
    • Over $100 million in charges covered annually under the expanded network arrangements
    • Nearly $3 million in annual savings – an additional 7% below bill review reductions
Ensuring Provider Data Quality

Provider self-service to encourage routine updates

 

Predictive data cleansing through sophisticated data mining

 

Full time employed, U.S.-based outbound call center

    Case Study: Recovering Overpayments
    Government – Payment IntegrityMultiPlan analysis of paid claims for a non-profit Medicare Advantage special needs plan identified inappropriate admissions as a particular vulnerability, calling for:
    • Special audit attention for the 15,000-member Medicare Advantage plan
    • Expansion to the 400,000-member Medicaid plan, with the state’s adoption of DRG pricing
    Government – Payment IntegrityMultiPlan implemented a targeted analysis, review and outreach program that:
    • Targets short-stay hospital admissions
    • Minimizes provider abrasion through careful case selection
    • Stands by findings and supports resolution with both contracted and non-contracted providers
    Government – Payment IntegrityMultiPlan has delivered significant savings for the Medicare Advantage plan, and just expanded the process to the Medicaid plan:
    • Identified issues in 62% of cases reviewed
    • Reached recovery agreement on nearly 80% of cases challenged, generating $3,000 per case reviewed
    • Upheld decisions on 74% of cases appealed
    • Handled overturns using voluntary peer-to-peer discussion to avoid the time and expense of formal appeals
Believe It or Not: What Our Payment Integrity Services Find
Contradictory Procedures:

Placement of a gastric restrictive lap band . . .

reported with a total gastrectomy (removal of stomach)

Unusual Combinations:

Breast reconstruction surgery . . .

reported with revision of breast reconstruction on the same day

Suspect Provider Patterns:

Physical therapist reports the same services on every bill . . .

for every patient

    Case Study: Retaining Important Business
    Commercial – Analytics-BasedMultiPlan analysis helped a third-party administrator defend against a competitor’s push to implement Medicare pricing by:
    • Significantly improving savings for the employer and its members
    • Engaging important providers in the new process
    • Preserving the community’s provider-patient relationships
    Commercial – Analytics-BasedMultiPlan strategically combined network access with reference-based pricing:
    • PHCS Network access to preserve existing member relationships with their healthcare professionals
    • Data iSight pricing to deliver fair, consistent and transparent pricing of hospital and other facility claims
    Commercial – Analytics-BasedMultiPlan’s revised solution delivers greater savings on more claims:
    • 10-point improvement in savings
    • 8-point increase in charges reduced
    • Guaranteed member protections on 62% of claims reduced, compared to 0% with Medicare-based pricing
Data iSight in Action

An urban teaching hospital with 150-300 beds submitted a $27,268 claim for a Cesarean Section. Data iSight analysis determined the charges to be 364% of the hospital’s cost to deliver the service.

Using its patented benchmarking methodology, Data iSight compared the claim to 103,212 claims with the same APR-DRG and severity level from 266 other urban teaching hospitals of the same size. The median, wage adjusted cost of the benchmark group was $5,384. Data iSight recommended a reimbursement at which 75% of the facilities in the benchmark group would be profitable, generating a 47% discount and a reasonable profit to the hospital.

    Case Study: Navigating a Challenging Environment
    Property and Casualty – Network-BasedAn auto medical services provider wanted to distinguish its network-based cost management program to sensitive auto insurance carriers by demonstrating:
    • Minimal provider noise through the use of network contracts to reduce medical cost
    • Effective dispute resolution processing
    Property and Casualty – Network-BasedMultiPlan customized a process for the company to document success in resolving disputes:
    • Custom reports to oversee its internal escalation process and compliance with turnaround time requirements
    • Monitoring tool to gauge its staff’s compliance with internal processes and guidelines
    • Proactive dispute resolution to alleviate carrier concerns, often more perception than reality
    Property and Casualty – Network-BasedMultiPlan’s program enables superior carrier retention:
    • Dispute rate less than 1% of bills processed
    • Consistent achievement of contractual turnaround time obligations
What's Your Emerging Pain Point?Market dynamics are just that — dynamic. MultiPlan has the intelligence engine to interpret your cost management performance, technology-driven services designed for flexibility, and 37 years of experience helping healthcare payers adapt as their needs evolve. Contact us