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©2013 Premier Healthcare Exchange, Inc. Y OU ’ VE G OT THE P OWER : H OW TO M ANAGE YOUR H IGH D OLLAR C LAIMS
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©2013 Premier Healthcare Exchange, Inc.©2014 Premier Healthcare Exchange, Inc. W HO IS PHX A customer ‘first’ healthcare cost management company headquartered in Bedminster, NJ with a staff size of 225+ Our objective is to provide the most innovative, comprehensive and effective cost management solutions at one destination Our expertise includes network management and customization, claims editing, bill review & audit, out-of-network services and customer support In 2014 our savings are expected to exceed $300 million from PHX core services to 250+ clients
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©2013 Premier Healthcare Exchange, Inc. Network Management > ProPoint Primary > ProPoint National Access > Custom Network Solutions Network Management > ProPoint Primary > ProPoint National Access > Custom Network Solutions Payment Management > Select > Select Plus > Direct > RedPlus Payment Management > Select > Select Plus > Direct > RedPlus Claims Integrity > Claims Editing > Bill Review & Audit (post and pre payment) > Out-of-Network Services Claims Integrity > Claims Editing > Bill Review & Audit (post and pre payment) > Out-of-Network Services Trust in AccuracyTrust in SavingsTrust in Access ©2014 Premier Healthcare Exchange, Inc. C OST M ANAGEMENT S OLUTION
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©2013 Premier Healthcare Exchange, Inc.©2014 Premier Healthcare Exchange, Inc. America’s Health Insurance Plans (AHIP), found that from 2008 to 2010 inpatient hospital prices increased 8.2% per year with wide variation in price levels and growth rates across states and localities.* *March 2013 issue of the American Journal of Managed Care (AJMC) I NDUSTRY G ROWTH
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©2013 Premier Healthcare Exchange, Inc.©2014 Premier Healthcare Exchange, Inc. M OST C OMMON B ILLING E RRORS Incorrect Unit/Quantity Billed Duplicate Line Item Charge Level of Care Assignment Unsupported or Undocumented Service Operating Room and Recovery Room Time Units Billing Compliance/Unbundling
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©2013 Premier Healthcare Exchange, Inc. Pre-Payment Process
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©2013 Premier Healthcare Exchange, Inc. Pre-payment, line-by-line, desktop review of in & out-of–network claims billed with % off discounts and DRG Carve Outs Expert team staffed with registered nurses, certified coders, pharmacist, Medical Director, and panel of physicians Secured Savings = Letter of Agreement (LOA) Dedicated staff to retrieve pertinent medical records at no cost Compliment case management/utilization review initiatives Compliance with state mandates + Provider limitations Hands on manual audit = greater results ©2014 Premier Healthcare Exchange, Inc. B ILL R EVIEW AND A UDIT
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©2013 Premier Healthcare Exchange, Inc. THREE TIER APPROACH Line by line clinical audit of medical records; Review for billing discrepancies, duplicate charges, waste & quality of care and risk management issues Financial Review Experimental/ Investigational & Medical Necessity Review Cost vs. charge review; Utilize tools such as AWP, Implant invoice/pricing database & PPO network analysis Concrete recommendations based on groups plan language exclusion definitions of E/I and MN supported by industry recognizes guidelines FDA, Medicare, standard of care compendiums and specialty peer review physicians Clinical Review B ILL R EVIEW AND A UDIT
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©2013 Premier Healthcare Exchange, Inc. B ILL R EVIEW AND A UDIT F OCUS Revenue Code 278 – Implants > Orthopedic > Spinal > Cardiac Revenue Code 636 – J Codes/Drugs > Chemotherapy > IVIG > Factor VII Level of Care (NICU, ICU) Respiratory (Nitric Oxide, ECMO, Vent) Experimental/Investigational (All therapies) Hospital Acquired Conditions Ambulatory Surgical Center
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©2013 Premier Healthcare Exchange, Inc. Leukemia with Clofarabine Intervention Total billed: $262,386 Revenue code 636 - high dollar specialty drug review J Code 9027-Clofarabine 1 mg Single use vial/20 mg per vial Units billed did not correspond to MD order Revised UB secured reflecting appropriate unit count Revised UB-04 $38,812 $223,574 (85%) In Savings $223,574 (85%) In Savings C ASE S TUDY #1
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©2013 Premier Healthcare Exchange, Inc. Placement of Endurant Abdominal Aortic Aneurism Total billed: $106,734 Revenue code 278 - implant review Line by line review of detailed bill against medical record Based on historical information and implant cost benchmarks, charge appeared to be atypical for device. Charge addressed with Provider Provider confirmed charge capture for this device was not correct as billed. Revised UB-04 $38,870 $67,864 (64%) In Savings $67,864 (64%) In Savings C ASE S TUDY #2
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©2013 Premier Healthcare Exchange, Inc. Code EditsR&C Benchmarks Medicare Benchmarks PHX Historical Provider Database Clinical Expertise PHX Network Affiliates PHX Export PHX Out-of-Network Service ©2014 Premier Healthcare Exchange, Inc. PHX Claim Negotiations PHX Choice Network = Import/Export of files = PHX Net Cost of Claim Tools = PHX Savings Channels 3 O UT - OF -N ETWORK /N ET C OST OF A C LAIM
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©2013 Premier Healthcare Exchange, Inc. Post Payment Process
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©2013 Premier Healthcare Exchange, Inc. Post payment audits of Institutional claims with a focus on claims with DRG carve outs, revenue code outliers & % off discounts Data Mining functionality to identify clinical areas of focus based on post payment claim data + Past audit results B ILL R EVIEW AND A UDIT S ERVICES Analysis of Contracts Clinical Audit In depth clinical audit based on detailed itemization & clinical documentation conducted by a licensed clinician Analysis & audit in conjunction with payor contracts, medical & payment policies to uncover recoverable opportunities & savings Compliance with state mandates + Provider limitations Hands-on manual audit delivers greater results Two Tier Approach of Audit to identify overpayments & recoverable savings
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©2013 Premier Healthcare Exchange, Inc. Client Case Study
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©2013 Premier Healthcare Exchange, Inc.©2014 Premier Healthcare Exchange, Inc. C ASE S TUDY P AYOR F ACTS National Market Payor Current Member enrollment over 400,000 Developed a proprietary Managed Care Network and access’s multiple leased networks Current Cost Containment Strategy includes: Post payment audit vendor SIU Division Staff of Nurse Auditors to review certain claim types
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©2013 Premier Healthcare Exchange, Inc. ANNUAL SAVINGS $16,792,598 Savings per Claim Successful Claims = 1,174 $14,303 ©2014 Premier Healthcare Exchange, Inc. N ATIONAL C ARRIER C ASE S TUDY
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©2013 Premier Healthcare Exchange, Inc. P OWER OF P ARTNERSHIP
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©2013 Premier Healthcare Exchange, Inc.©2014 Premier Healthcare Exchange, Inc.
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©2013 Premier Healthcare Exchange, Inc. ©2014 Premier Healthcare Exchange, Inc. C ONTACT I NFORMATION Bryan Russo Director of Sales 908-367-3112 x361 brusso@phx-online.com Ingrid Crowley Director, Bill Review and Audit 908-315-7013 x250 icrowley@phx-online.com www.phx-online.com
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