Actual Case Studies

The following are some actual examples of savings that have been realized through our processes:

Renal Dialysis Re-Pricing Program

In 2006, a 32-year-old patient received renal dialysis in New York City from one of the two largest companies that provide renal dialysis services. Monthly charges were running $44,276.80.

• Recommended repricing resulted in a 74% reduction in payment realizing $393,177 of annual savings. Provider appealed; determination upheld by the plan document.

Transplant Tertiary Network

A 39-year-old patient required a kidney transplant and was in his primary network. The primary network had available a 25% discount.

• SCM was able to offer them a case rate at the same facility, utilizing the same provider, with an additional net savings (above the 25% available from primary) of 27.1% off the primary network's rate;
• Overall savings from original billed charges was 55.6%.

Cancer Care Management

A member had lung cancer and was treated with IV Etoposide. Our cancer management involvement, and discussion with the provider and family, transitioned the individual to an equally-effective oral Etoposide. Neulasta was arranged to be given in the home at the appropriate timing maximizing the drug's efficacy. This drug is given to help limit hospitalizations related to neutropenia.

• Through our involvement, the patient was directed to in-network providers, saving the plan 32% of billed charges;
• The change to oral chemo avoided pharmacy costs (i.e.: IV drugs, fluids) and administration costs, yielding savings per day of $532, two days per cycle; savings is $1,064 x 10 cycles = $10,640;
• Direction to in-network facilities for appointments and treatments yielded savings of $1,000;
• Self-administration of medication yielded savings of $50 per visit; 10 visits avoided = $500 saved;
• Estimated two-day hospitalization avoided with increased efficacy of Neulasta, at $2,700/day at primary network rate for hospitalization, cost avoided = $5,400;
• The result was total savings of $19,740 with increased quality to patient.

Maternity Management/NeoNate

A premature infant girl was born at 28 weeks, weighing 2 lbs, 5oz. The baby did well, was considered a "feeder" and "grower," and was discharged early due to our efforts.

• Our Case Manager effected early discharge from in-patient care, normally kept till due date; discharged at 38 weeks, two weeks before anticipated discharge; savings of 14 days in the NICU was $35,000;
• We steered the patient to PPO Home Care providers for apnea monitor and two skilled nursing visits for teaching;
• We negotiated the home care Synagis pricing for home administration; price, including skilled nursing, was $800 x 6 doses (AWP -15%) for savings of $240 per dose or $1440 for series;
• Total savings realized on this case was $36,440.

Advanced Funding/Claims Negotiation

We received from a client in Houston, Texas, a claim for $1,035,698.25. The primary PPO discount was $334,426.79 = 32% off.

• Our agreement with the provider totaled a 45% discount for an additional 13% discount off the primary PPO discount, resulting in net savings to the bottom-line of an additional $95,000.

Clinical/Financial Audit

In an audit of a home infusion case, the original charges for services totaled $140,025.

• Upon audit of the home infusion company, we identified multiple instances of overcharging;
• Adjusted post audit charges totaled $65,220; savings to the group = $74,805;
• We obtained sign-off for the audit and ensured there was no balance billing to the patient.

Implant Negotiation

This Wisconsin member required an implanted pacemaker to manage his heart condition. Billed charges for the procedure were $176,076.96. The charges for the hardware alone were $139,887.

• Our negotiated charges for the procedure totaled $82,835.02.Savings as a result of negotiation were $93,241.94; nearly a 53% savings to the group.

Bill Audit/Fraud Detection

We reviewed the bills for a major stop loss carrier on an infant in-patient admission to a Chicago hospital. Billed charges totaled about $25,000/day. The facility was a participating primary PPO facility with a 22% discount. We reviewed the first two interim claims and found inappropriate billing resulting in $257,956 above the 22% primary PPO discount.

• 1st claim total billed was $790,836.95; inappropriate billing of $135,097; recommended payment = $655,739.95;
• 2nd claim total billed was $697,133; inappropriate billing of $122,859; recommended payment = $574,274;
• Total saved = $257,956.