Leverage Medicare-based pricing to drive increased savings in your out-of-network cost containment program, or as a replacement to today’s PPO networks.
The healthcare landscape has never gone through as significant a change as it is experiencing right now. Medicare-based pricing, or a multiple of Medicare, is becoming the standard in PPO replacement, out-of-network reimbursement, and aiding in the claim negotiation process. Payers, third party administrators, self-insured employers, and others managing healthcare claims risk are looking to replace or augment their existing primary and supplemental network programs by using Medicare rates to drive increased plan savings.
Most plans have realized they need significant savings through fundamental -- rather than incremental -- change to operate successfully post-healthcare reform.
Medicare is a known quantity and provides transparency to the provider community. It is understood and can be explained throughout the industry, and is superior to proprietary usual and customary solutions.
Other usual and customary methods are risky due to the proprietary nature of the methodologies being used (less defensible), financial incentives (to maximize claim reductions), and outdated information.
Medicare-based repricing offers a significant improvement in savings over all existing cost containment solutions.
Organizations looking for significant, game-changing savings are turning towards Medicare-based pricing due to the combination of increased persistency (“hit rate”) and the overall reduction in billed charges.
ClearHealth Strategies is uniquely qualified to provide out-of-network cost containment using a strategic blend of Medicare-based pricing, claim negotiations, and supplemental network discounts.
Payers, third-party administrators (TPA¹s), employers, cost containment management firms, and other entities with health claim exposure choose ClearHealth for its comprehensive Medicare-based pricing program, complete with appeal management and patient advocacy, and customized based on the group, geography, product, or other parameters. This approach is best in class and serves as a model for the industry¹s use of Medicare-based pricing.
ClearHealth offers state-of-the-art and industry leading solutions to negotiate and reduce financial risk associated with out-of-network claims. ClearHealth has built its systems based on demands from some of the health industry¹s largest companies and has widely configurable rules to handle claims based on the rules provided by the client. Medicare-based pricing and other benchmarks are used prevalently to obtain the maximum discount possible.
For those organizations looking to reduce the number of vendors under management and consolidate operations, or for those looking to increase automation, reporting capabilities, and adding cost containment solutions more easily to the out-of-network portfolio, ClearHealth acts as a routing solution between new or existing supplemental network partners. When combined with Medicare-based pricing and/or Claim Negotiation capabilities, a total strategic solution is established.
ClearHealth delivers comprehensive Medicare-based pricing programs that are fully configurable to allow your organization to achieve maximum savings while using a cost containment strategy tailored to meet your strategic goals. Health plans, third-party administrators (TPA’s), self-insured employers, and other cost containment organizations look to ClearHealth to provide a complete outsourced program offered in a turnkey model complete with embedded member advocacy and appeal management services.
ClearHealth Strategies leverages best-in-class technology which has the unique ability to price all 16 Medicare fee schedules and includes all necessary edits mandated by Medicare.
The data is sourced from the Centers for Medicare & Medicaid Services (CMS) and is updated according to their release schedules. Data from third party pricing platforms are licensed to provide benchmark pricing to ensure 100% accurate repricing.
ClearHealth provides appeal management services, which can be configured to meet your organizational goals.
This component of the program is crucial for those looking to minimize potential provider “noise” and member disruption. ClearHealth claim advocates will educate the provider or member how the claims were priced and strive to retain savings on all appeals.
The ClearHealth Medicare-based repricing program is completely customizable.
Claim handling rules can be customized by claim type, geography, group, provider, or plan design. All customization options can be handled via a Web-based configuration portal.
ClearHealth provides partners and customers with a Web-based reporting portal to view real-time program results by group, claim type, date, or provider.
“The ClearHealth program has enabled our company to increase savings in our cost containment program by almost 50%.”
“Being able to configure the program based on carve outs, group or claim type, provider-specific and state-specific rules, geography, and type of care (e.g., emergency treatment) gives our customers great flexibility in how they choose to implement a Medicare-based repricing program.”
“Overall we see less than 5% of the claims challenged on appeal and ClearHealth works very closely with us to help us retain the savings on those claims that are appealed.”
“The rapid turnaround time associated with obtaining the Medicare-based price, and the manner in which the results are returned, have enabled us to add this program while continuing to meet our aggressive claim payment turnaround times.”
Let us show you how we can improve out-of-network risk management and cost containment for your company.