Published on March 6, 2014
Powerful solutions for today’s healthcare marketplace
We are a National Healthcare Cost Containment organization that focuses on high cost areas of Healthcare for Employee Benefits and Workers' Compensation. Our services benefit self-funded employers seeking to control healthcare costs, Third Party Administrators needing to carve out expensive procedures for their clients, workers' compensation insurance carriers/TPAs looking to lower costs, and any other Union Fund or Municipality that is looking to bring more value to their self-funded clients Relevant includes an executive management team and scheduling department with a combined experience of over 250,000 diagnostic claims managed which resulted in more than $250 million in savings. 2
The Problem Healthcare costs continue to rise at significant rates. “The Bitter Pill” – March, 2013 Time Magazine Article re: the COST of healthcare services in the hospital systems of the US With healthcare reform, cost shifting (especially in the hospital systems) to the commercial space will be significant. Certain areas and specialties of treatment continue to show the greatest increases in cost: Radiology Dialysis Oncology Pharmacy Inpatient Hospital Claims/Outpatient Surgery 3
The Problem Diagnostic Radiology is the fastest growing component of medical expense 20% growth rate 2x faster than prescription drugs and faster than overall healthcare spending Upwards of 10%+ of Total, Annual Medical Spend Dialysis costs are one of the most unpredictable areas facing healthcare finance today. One patient could be billed less than $120,000 annually and another could easily exceed $1,000,000. 2 providers control 90% of market 4
The Problem Oncology: 1% of covered plan members will have cancer at any given time which can account for more than 15% of total plan costs, according to published sources. Pharmacy costs will continue to represent a significant component of any payor’s total spend annually especially with the anticipated spike in the utilization of specialty drugs. Hospital Claims: General Accounting Office report showed 95+% of all hospital claims have errors, overcharges, charges for services never rendered or not associated with the diagnosis. *See Time Magazine, March 4th 2013: “The Bitter Pill”. Obamacare also causing increases in charge masters due to cost 5 shift to commercial space.
Products/ Services • National Advanced Diagnostic Imaging Network • Services are FREE to Client • Hospital Medical Bill Review/Audit • FREE to Client-Relevant fee based on savings • Dialysis & Oncology Claims Settlement • FREE to Client-Relevant fee based on savings • Pharmacy Benefit Management • Several delivery methods including a risk based program with price/savings guarantees 6
Relevant Healthcare Saves Clients Money Clients substantially lower costs through Relevant’s Programs: Radiology: • Average Savings Per Test = $500.00 • Average utilization is 13% of total membership per year. Example: 5,000 lives = 650 tests/year x $500 = $325,000.00/year Dialysis: • Average Savings PMPM in the program = $20,553.00 • Average Savings % = 75.1% 7
Relevant Healthcare Saves Clients Money Hospital Medical Bill Review/Audit: • • • • Success Rate = 96% Average In-Network Savings = 24% Average Out-of-Network Savings = 50% Average Overall Savings = 32% Oncology: • Average Savings PMPM in the program = $5,650.00 • Average Savings % = 24.6% Pharmacy • Average savings = 8-15%. TRANSPARENCY • Savings are Guaranteed. Program is Risk-Based/ReInsured • Analytical approach: uncovers Spread Pricing, inflated AWP, private label MAC programs, etc 8
Relevant Healthcare Saves Clients Money Additional Savings can be achieved by gaining leverage to re-negotiate Stop Loss rates by implementing Relevant’s programs. Many stop loss carriers are extremely interested in their clients implementing these programs as it mitigates their risk as well, especially on the high dollar claims found within the hospital systems, or with ESRD and cancer related claims. 9
Relevant Healthcare’s Radiology Program FREE to implement and utilize the program, including member materials. No PEPM, % of savings, implementation or other fees. Concierge Service Package for Members/Ordering Physicians Savings = 30% to 50+% less than Payor’s current network discounts (over $500/test) Facilities must meet NCQA standards ACR Credentialing of Radiologists 100% quality guarantee on films/images produced at Relevant’s facilities The TPA adjudicates the bill at 100% of billed charges, and full payment is made to Network 10
How to Get Started for Radiology? Relevant Healthcare handles it all & only needs… Billing address 800# to verify eligibility Instructions re: where to direct a patient who is found “in-eligible” Total number of lives on the Plan (for ID Cards/Flyers and staffing) Administrator loads single TIN# All referrals to Relevant Healthcare for advanced radiology will be billed on the same TIN# Relevant logo on current ID cards? Yields the highest penetration If needed, Relevant will produce ID Cards/Member information for clients for distribution Reporting – all reports measuring the value of this program will be provided by your Dedicated Account Manager. 11
Relevant’s Dialysis & Oncology Programs FREE to implement and utilize the program, which includes a full review of the Plan Document by our attorneys with any additional, legal language provided to support the process. Team of industry experts/insiders performing the reviewing and negotiating the discounts directly and includes clinical system review/edits along with accessing our data of ‘Accepted Reimbursements’ used to provide the reference for reimbursement. Success rate on in-network claims of 50% and out-of-network claims as high as 99.9% National average saving of 24% to 75+% less than Payor’s current network discounts Contingency Based – no savings achieved, no fee for the Review 12
How to Get Started for Oncology/Dialysis? Relevant Healthcare handles it all & only needs… Copy of the Plan Document for Review Provide additional language if needed Implement a workflow of receiving claims (EDI, Fax, FTP, Etc.) and forwarding invoices Implement process for Relevant to handle all appeals or potential balance bills. Reporting – all reports measuring the value of this program will be provided by your Dedicated Account Manager. 13
Relevant’s Hospital Medical Bill Review/Audit Program FREE to implement and utilize the program, which includes a full review of the Plan Document by our attorneys with any additional, legal language provided to support the process. Comprehensive and defensible databases to help compare the relationship of billed charges to what are fair and reasonable charges for a specific type of provider for a specific type of service/procedure in a specific geographic region. Focus on accurate billing and coding. National average saving of 32% Contingency Based – no savings achieved, no fee for the Review Relevant Healthcare becomes the Fiduciary even providing legal assistance if needed. 14
How to Get Started for Hospital Medical Bill Review and Audit? Relevant Healthcare handles it all & only needs… Copy of the Plan Document for Review Provide additional language if needed Implement a workflow of receiving any/all claims over $15K (EDI, Fax, FTP, Etc.) and forwarding invoices Implement process for Relevant to handle appeals or potential balance bills. Reporting – all reports measuring the value of this program will be provided by your Dedicated Account Manager. 15
Relevant’s Pharmacy Benefit Management Savings range from 8-15%+ compared to current PBM Ability to guarantee claim rates through reinsurance Efficient retail claims processing within our nationwide network of 63,000+ pharmacies 24/7 Customer Service and Mail Order Home Delivery Service Multiple program offerings to fit any payor’s specific needs – Self Insured, Fixed Cost, Rx Savings Card, **Non-Profit Program Can provide a free, guaranteed savings proposal 16
How to Get Started for Pharmacy Benefit Management? Relevant Healthcare handles it all & only needs… Claims Data for free cost analysis and a Proposal of Guaranteed Savings Discussion of the type of what program delivery design is needed and fits best within the client Reporting – all reports measuring the value of this program will be provided by your Dedicated Account Manager. 17
Innovative People – Innovative Products – Innovative Solutions Forging Long-Term Partnerships 18
Calcification Inhibitors in CKD and Dialysis Patients
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Quality improvement ... A QI program in a health care organization often begins ... where the costs to make the changes are offset by the cost savings ...