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Starting From Scratch
59 year old Female Intracranial haemorrhage Hospital in Missouri
18 Day Admission
Billed: $139,000 Saved: $55,000 Discount: 40% GEM was asked to negotiate this claim at a veteran’s hospital – typically these providers do not contract with networks so the client was looking at paying the bill in full before GEM took the case on. The negotiator conducted a thorough review of the bill and made a proposal based on Medicare rates. After several exchanges, he was able to obtain a signed agreement for $83,534.50, getting a 40% discount for the client. Third Time's a Charm
51 year old Male Treatment of Myeloid leukemia Hospital in New York
97 day admission
Billed: $1,365,842.59 Saved: $522,000 in billing errors Discount: 35% on balance A client approached GEM with a case which had already passed through another auditor without result. The costs were far in excess of the norm, even for cancer treatment, and the client was not satisfied with the 35% network discount in place. 2 prior reviews had not produced a meaningful answer for the inflated charges. GEM conducted an exhaustive clinical review of the bill and while the treatment rendered appeared to be in order, one drug stood out as being extremely expensive compared to wholesale costs. The provider maintained that all was in order but the negotiator persisted and required a third audit to be done. It was finally discovered that the facility’s system was charging the price of an entire case for each syringe administered; every dose was charged at 30 times the intended rate. The billing error was corrected and the billed charges reduced by $522,000. The client was then able to run the bill through their network for the 35% discount. Tailoring to the case
65 year old male Coronary Atherosclerosis of Native Coronary Artery Bypass surgery with Cardiac Catheter Hospital in Missouri
18 day admission
Billed: $146,000 Saved: $56,000 Discount: 38% A careful review of this claim revealed that the 5% network discount in place did not satisfy the client’s Usual and Customary policy wording, and the negotiator measured the hospital’s charges against industry benchmarks to determine a fair payment for services rendered. The negotiator approached the facility with an offer. The billing office was initially reluctant to go above the network discount but with the backing of objective data on the hospital’s costs, the negotiator was finally able to get the provider to sign off on a 38% discount, resulting in an additional 33% discount, or $49,000 in additional savings. We can do this the easy way or the hard way…
44 year old Male Displacement of thoracic or lumbar intervertebral disc Doctor in New York
Outpatient Surgery
Billed: $178,500 Saved: $143,000 Discount: 80% When GEM received this out-of-network claim for negotiations, the negotiator measured billed charges against industry benchmarks and discovered that the doctor had billed nearly 20 times the Medicare-allowable rate. Despite this, the doctor initially offered only 20% off of billed charges and would not consider a more reasonable settlement. The negotiator consulted with the client about options moving forward and they agreed that a tough approach was going to be needed. The negotiator returned to the table with an offer: the provider could accept a very reasonable payment of $37,500 USD as full and final payment, or GEM would be forced to adhere strictly to the policy’s Usual and Customary wording, and issue a payment of approximately $17,000. The next day, the doctor had accepted the first offer, and GEM was able to save the client over $140,000 with a signoff. Let's look behind door number 2
58 year old male Neck surgery Hospital in Pennsylvania
5 day admission
Billed: $151,000 Saved: $144,000 Discount: 95% GEM was approached to negotiate an upcoming, highly specialized neck surgery. The patient’s doctor had recommended a hospital where the surgeon had admitting rights for the procedure. GEM’s careful review showed that the procedure would be very costly at the chosen hospital. The negotiator investigated other hospitals in the area and proposed an alternative provider nearby with much better financial prospects. The surgeon did not have admitting rights at the second facility but GEM strongly believed in their recommendation and provided assistance in gaining the proper rights for the surgeon. Charges at the chosen hospital totaled $151,333. Payment according to the secured agreement totaled $6,850, a 95% discount. It was estimated that payment to the first facility would have come to approximately $165,000, from billed charges of $220,000. By intervening early and reviewing financials before the procedure took place GEM had saved the client a potential $160,000. Back in Time
21 year old male Spinal untethering Outpatient surgery Hospital in Colorado
Outpatient Surgery
Billed: $48,000 Saved: $15,000 Discount: 30% GEM’s client asked for help negotiating a spinal surgery which their member was about to have. An offer for a 20% discount had been extended by the surgeon and the client wanted to know if GEM could do better. Time was critical as the surgeon would not move forward with the procedure until an agreement was in place. The negotiator asked to review the information on the proposed procedure to determine a reasonable rate. She took her findings back to the provider and an agreement was reached for a 30% discount, 10 points higher than the initial offer, and representing an additional $5,000 in savings for the client.
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