Redirect Providers and Members to More Cost Effective Locations

Leverage comprehensive data and analytics to guide prior authorization processes – encourage more cost effective sites of service.

Payer Value: Lower Medical Cost of Care

Market Challenge: Providers are typically unaware of reimbursement rates associated with procedures at different medical facilities.

For example, surgeons performing the same surgical procedure at multiple locations are generally unaware of the wide price variances, which can range as much as 400% – 500% among network providers for the same procedure.

Guide providers and members to cost effective locations

How Comparative Analytics Can Help:

Enhance prior authorization – Simply identify opportunities to move high volume services to more cost effective settings.

  • Identify procedures that are prone to wasteful utilization.
  • Inform providers about costs related to a specific site of service.
  • Obtain insights into quality outcomes associated with each facility.

Reveal abnormal or inconsistent billing patterns within episodes of care.

  • Identify aberrant billing patterns within an episode.
  • Inform providers of these abnormal or inconsistent billing patterns.
  • Identify opportunities to enhance reimbursement practices.

For example: The length of stay for a particular location is running 2 days longer than the average stay. Or, perhaps a provider is billing for an upper GI with every colonoscopy, which is not common protocol. Analyze the cost variance of a procedure and compare it to any clinical variance that may exist.

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Over $5 Million
Average Savings Per State*

Colonoscopy: $1.85M
Upper GI Endoscopy: $3.63M
*Based on a case study conducted in two average size states.

Influence referral patterns closer to the point of care.

  • Arm referring providers and patients with episode of care data to make informed decisions.
  • Give providers and members access to episode of care data through the Health Plan’s member and provider portals.
  • Implement procedures to support provider and member navigation strategies by defining the priorities and measuring outcomes.

For example: Identify high cost or high volume procedures by provider and facility to begin prioritizing initiatives.

Surgeon Site of Service Suggested Procedures.

Leverage episode of care comparative data to identify specialties that have the greatest impact on your medical cost of care.

Achieve $4.76 million in savings by redirecting providers to lower cost facilities – representing 43% in savings. Data based on two procedures, in two states across 25 surgeon practices.

Suggested procedures listed in priority order based on historical analytics data.

  • Colonoscopy – Diagnostic
  • Colonoscopy – Surgical
  • Upper GI Endoscopy – Surgical
  • Gallbladder Removal
  • Knee Arthroscopy
  • Cataract Surgery
  • Nasal Endoscopy – Diagnostic
  • Shoulder Arthroscopy
  • Tonsil and Adenoid Removal
  • Ear Tubes
  • Upper GI Endoscopy – Diagnostic
  • Colposcopy – Surgical (Scope of the cervix, etc)
  • Cystoscopy (Endoscopy of the bladder)
  • Nasal or Sinus Endoscopy – Surgical
  • Hernia Repair
  • Carpal Tunnel Release
  • Hysteroscopy (Scope of the uterus)
  • Spinal Fusion – Lumbar
  • Knee Replacement
  • Hip Replacement

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To learn more about how to leverage comparative data to redirect providers and members to lower cost locations, contact us today.

Download the Use Case: Redirect Providers and Members to More Cost Effective Locations PDF