Insights

3 Ways to Break Through the Medical Cost Containment Ceiling

When savings have plateaued, a new approach to cost containment that applies outcome-driven analysis and clinical expertise may be in order.

While traditional bill review catches the vast majority of issues and has resulted in myriad cost reductions, payers are still missing out on an estimated $3.5 million in savings for every $100 million in medical charges.

Luckily, a new system for medical cost containment has been unveiled and it has the potential to provide aggressive savings above what is currently being achieved.

NexGen Advantage℠ is the industry’s first single solution that uses analytics, technology, and clinical expertise to ensure accurate and fair medical payment of each and every bill. Employed post-bill review, this new solution is designed to maximize medical cost containment specifically for the workers’ comp industry. Here’s how:

Calculates complexities

Common bill review catches a lot of errors, but most systems are not set up to do a deep dive. Bill codes are assessed using software and triggers that are programmed to primarily look for coding conflicts that indicate errors. For example, if it’s a workers’ comp bill, why is there a code for a  thyroid scan on here?

Complex cases, however, are not always this clear or straightforward and can slip through the cracks. The NexGen system relies on nuanced algorithms, leveraging over 200 million code combinations from the group health industry to maximize savings by recognizing complex bill patterns that may require clinical intervention.

Includes Peer-to-Peer Clinical Conversations

Approximately 70% of flagged billing issues require some kind knowledgeable human assessment. Whether it’s complex coding errors like “return to surgery” at a physician’s office, or suspicious billing patterns like a patient with 17 facet joint injections being billed in a single year,  only peer-to-peer evaluation by a physician or expert coder can determine if these bills are clinically appropriate.

NexGen Advantage employs peer-to-peer conversations with providers about benchmarks, coding and payments, and offers online access to data that helps all parties engage in non-confrontational discussions to arrive at the right decision.

Strategic discount arrangements

In-network discounts don’t always result in the greatest savings available and often come with complicated stacking structures and hidden access fees; out of network solutions add vendor management burdens and even more access fees. NexGen Advantage assesses the potential savings possible across all channels at once–appropriateness of charges, network rates, benchmarked costs and whether negotiation is possible and desirable–to apply the most advantageous discount arrangement possible.

Ready to break through the savings ceiling and realize more streamlined, more efficient results and payment integrity? Learn more about MedRisk’s NexGen.

We’re restoring movement, empowering recovery, and driving progress in workers’ compensation.

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