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GEMDeal | GEM-MD | GEMDeal-In | GEMLive | StrataGEM | GEMCode
Back to Case Studies | Spring 2011 | Summer 2011 Every Case Counts
25-year-old Male Closed Fracture of Pelvis, 60-Day Admission Open Reduction of Fracture with Internal Fixation Hospital in Tennessee 60-Day Admission
Billed: $1,125,000 Saved: $619,000 Discount: 55% GEM received this catastrophic claim for Out-of-Network negotiation 20 days after the patient’s discharge. A million-dollar-plus bill demands extra attention and a percentage-off deal will seldom do. A careful review of hospital-specific data and GEM’s past history with the provider showed that GEM had great success in the past in achieving agreements based on Medicare-allowable rates for comparatively smaller claims. Following several in-depth conversations with the facility, GEM was able to leverage their past relationship with the facility to lock in a Medicare-based settlement that resulted in over $619,000 in savings. Toe-ing the Line
13-year-old Male Residual Foreign Body in Soft Tissue Incision and Removal of Foreign Body, Subcutaneous Tissues; Simple Doctor in California 2 Outpatient Surgeries Billed: $50,000
Saved: $40,000 Discount: 80% GEM received these 2 claims for removal of an ingrown toenail and treatment for a subsequent infection. The negotiator considered the charges excessive for a perfectly routine treatment and pointed out to the provider that they were charging about 50 times the Medicare-allowable amount. The provider claimed that the charges were justified, though they still offered a 50% discount. The negotiator immediately determined that even a 50% discount would still be far out of proportion to the treatment rendered and explained the situation to the client. Options considered were to simply pay a fair and reasonable amount for the services rendered and deny the rest of the claim, or to continue negotiations. GEM discussed the situation with its client and both agreed that GEM should continue to push for a fair settlement. After some tough discussions the provider signed off on a $5,000 case rate per treatment, resulting in a final discount of 80% for the client. Needle in a Haystack…?
33-year-old female Disorders of Menstruation Laproscopic Total Abdominal Hysterectomy Hospital in Texas Outpatient Surgery
Billed: $103,000 Saved: $55,000 Discount: 53% GEM received this In-Network claim with a 23% discount already in place. In preparing for discussions with the provider, the negotiator referred the bill to one of GEM’s dedicated nurses for auditing. The nurse’s findings, combined with a thorough review by GEM’s Medical Director, resulted in several billing irregularities being identified. These irregularities represented over 50% of the hospital charges submitted on the bill. With this information, the negotiator submitted the bill to the provider’s nurse auditing department for review. A short time later, the provider’s nurse auditor contacted GEM to advise that they acknowledged the billing errors and would be issuing a corrected bill in the amount of $48,574 – a savings of almost $55,000. As a result of GEM’s keen eye, knowledge and quick results, the client was then able to send the revised bill through the network for a discount representing further savings. “Hi, it’s GEM. Nice talking to you again.”
55-year-old Female Other and Unspecified Disorders of the Back Lumbar and Lumbosacral Fusion of the Anterior Column Hospital in Connecticut 5-Day Admission
Billed: $140,000 Saved: $61,000 Combined Discount: 44% GEM received this In-Network claim with an 8% discount already in place. The client asked GEM to initiate discussions with the hospital to negotiate a settlement more in line with the plan’s Usual and Customary payment language. The negotiator reviewed the hospital-specific data as well as past history with the provider which showed success in negotiating single case agreements based on Medicare-allowable rates. The negotiator approached the hospital with a similar offer, citing past agreements as the precedent. As a result, GEM saved the client $50,000 in addition to the $11,000 savings from the PPO. The Heart of the Matter: Cost
62-year-old Male Coronary Atherosclerosis Percutaneous Transluminal Coronary Angioplasty (PTCA) Hospital in Florida 2-Day Admission
Billed: $66,000 Saved: $35,000 Discount: 53% When GEM received this claim, a network discount of 16% was already in place. Looking to negotiate a settlement more in line with the plan’s Usual and Customary payment language, GEM reviewed past history with this provider, as well as the hospital-specific data. The negotiator’s research showed that the 16% discount offered was wildly disproportionate to the hospital’s costs. The negotiator approached the hospital with an offer, supporting the proposal with the acquired analytics. Following a review by the hospital and several conversations, the offer was accepted and GEM saved the client an additional $25,000 on top of the $10,500 savings from the PPO. Lock it in Early
54-year-old Female Malignant Neoplasm of Liver Antineoplastic Chemotherapy and Immunotherapy Hospital in Illinois Chemo - Ongoing
Billed: $560,000 Saved: $165,000 to date Discount: 30% GEM was approached for Out-of-Network negotiations on the first bill for ongoing chemotherapy treatment. The provider initially offered only a negligible discount of 10%. Knowing that this was only the first of many bills to come, the negotiator countered with an offer more in line with reasonable and customary rates. With persistence, GEM was finally able to secure an ongoing agreement with the provider, tripling the discount for the full course of the patient’s treatment. As a result of GEM’s unique solution the client has saved over $165,000 to date, with treatment still ongoing. Before Ever Receiving the Bill…
19-year-old Male Closed Fracture of Cervical Vertebra with Spinal Cord Injury Durable Medical Equipment Rehabilitation Facility Durable Medical Equipment
Billed: $167,000 Saved: $77,000 Discount: 46% GEM was contacted by the client to negotiate for a patient who had suffered a severe spinal cord injury and required durable medical equipment installed in his home prior to leaving the rehabilitation facility. The equipment included a portable lift, rails, power wheelchair, rehab bed, and other accessories. Using industry benchmarks to determine a fair and reasonable reimbursement for the required equipment, GEM presented an offer based on Medicare rates and was able to secure an agreement with the provider that resulted in over $77,000 in savings for the client. In addition, GEM was able to arrange that all the equipment was installed prior to the discharge of the patient. Protect the Patient
13-year-old Male Severe Burn of Lower Limb(s) Skin Graft Hospital in Arizona 16-Day Admission
Billed: $216,000 Saved: $138,000 Discount: 64% In preparation for Out-of-Network negotiations, GEM used industry benchmarks to determine the range for a fair and reasonable payment. The provider extended only a minimal 5% discount and would entertain no further offers of settlement. With productive negotiations stalled with the provider, GEM used industry benchmarks to determine a fair and reasonable reimbursement rate. GEM issued a payment in the amount of $61,450 with a letter of explanation outlining the criteria used. When the member received a bill for the alleged balance of $154,317, GEM immediately initiated its patient advocacy process to buffer him from the provider’s collection efforts and to protect the member’s credit. The message to the provider was clear: this matter was to be resolved directly with GEM and under no circumstances was the member to be contacted. With the patient removed from the discussion GEM was able to discuss the payment in detail with the provider. An amicable settlement for an additional payment of $15,000 was signed off as full and final payment. The account was closed and GEM was able to save the client over $138,000, all the while providing the member peace of mind in the handling of the claim. Plan for the Worst. Expect the Best.
59-year-old Female Intervertebral Disc Disorders Insertion or Replacement of Dual Array Rechargeable Neurostimulator Pulse Generator Hospital in Illinois Outpatient Surgery
Billed: $111,000 Saved: $76,000 Discount: 68% GEM received this In-Network claim for supplemental negotiation with a 20% discount already in place. With the implant charges making up over 90% of the bill, focus was put on determining the real cost of the implants and on the specific plan language. The provider was uncooperative, refusing to supply the cost invoices for the implants or discuss a reasonable settlement offer. The negotiator independently researched the costs of the implants and with the support of the plan language, issued an appropriate payment to the provider with a letter of explanation advising that GEM would be open to further discussions regarding the payment if necessary. The client was contacted by the provider within 2 weeks of the payment being issued; they had reviewed GEM’s payment explanation and acknowledged its validity. The provider advised the client that the balance had been written off and the account was now closed. With GEM’s initiative in addressing the issues quickly and thoroughly, they were able to save over $76,000 for the client. The Head Bone’s Connected to the…
Foot Bone? 17-year-old Female Open Wound of Leg, Knee and Ankle, Complicated Stitches Surgeon in New York Outpatient procedure
Billed: $39,000 Saved: $22,500 Discount: 58% In reviewing this Out-of-Network claim for negotiations, an audit of billing codes revealed two critical billing irregularities which had more than doubled the billed charges. The first code, a charge for $9,867 for Complex Repair Arms and/or Leg, was unbundled from another code already listed and billed. The second code, for Muscle Flap: Head and Neck, accounted for charges of $10,988. Given that the patient was seen for a cut on the leg, this code was identified as incorrect and denied. Both improper codes were cut as invalid charges. The ease and rapidity of GEM’s auditing service resulted in over $22,000 in savings for the client. Once in a Lifetime
61-year-old Male Disorders of the Gallbladder Laparoscopy, Surgical; Cholecystectomy Surgeon in Florida Surgery
Billed: $3,600 Saved: $1,900 Discount: 53% GEM received this Out-of-Network claim for negotiations and conducted a review through state-of-the-art bill auditing software. The audit revealed an unbundled code billed at $1,900, accounting for more than half of the charges and effectively billing for the same gall bladder removal twice. Further investigations showed that the 2 bills were for the same doctor, billed through two different billing providers. The negotiator contacted the physician’s office to advise them of their error and the bill was cancelled. Timely bill review and proactive provider management by GEM lead to a $1,900 savings for the client.  Top
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