In response to member requests for greater access to quality providers, clients continue to expand their HMO and PPO provider networks. In spite of this, however, many clients still experience significant out-of-network hospital and facility claim volume that contributes to escalating medical costs and price pressures, and clients are challenged to reduce these out-of-network costs.
The Solution
Viant offers two solutions to help manage out-of-network facility medical claim costs. After an out-of-network claim is submitted but before it is paid, Viant reviews the claim and makes a payment recommendation pursuant to parameters that a client has established based on its policy limitations and exclusions.
How it Works
Facility Outpatient U&C Review Service (OPR)
Outpatient claims are reviewed using Viant's Facility Outpatient Usual & Customary Review Service database, which combines submitted charge data with the CMS Ambulatory Payment Classification system. Viant's database is comprised of actual charges that providers have submitted to CMS and does not contain any Medicare reimbursement data. The charge data comes from more than 5,800 hospitals and over 30,000 other outpatient facility providers, and it contains no paid data, negotiated data, in-network data, relative value data, or Ingenix U&C data. Using its database of more than 500 million provider charges, Viant will compare the charge submitted by the facility to a corresponding U&C value for the facility's geographic area at the percentile the client has selected and report to the client the lesser of the submitted charge or the U&C amount. Viant reviews bills at each client's pre-specified parameters, including the percentile that will determine the reimbursement recommendation. A client using Viant's Outpatient U&C Review Service can see a significant increase in its savings on non-network facility claims.
Facility Inpatient Review Service (IPR)
Inpatient claims are reviewed using Viant's proprietary Cost-to-Charge (C2C) methodology. The exclusive data source for the C2C methodology is Medicare Cost Reports, which reports are prepared using the United States federal government's approved methodology to allocate both direct and indirect costs to each revenue center for each individual hospital. Viant's C2C methodology is based on the mathematical relationship between costs and charges as reflected in these reports. Viant uses the actual operating costs of each hospital and a consistent proportional margin allowance based on geographic norms and reports to its clients the results of its calculation for each claim. Viant's Inpatient Review Service can provide an effective cost containment mechanism that is sensitive to distinctions between different hospitals and different patients and yield significant savings for clients on inpatient facility claims.
Advantages
- A significant pre-payment cost control option, with strong savings performance
- Standard turnaround time (complete claims): 1-4 business days
- Flexible: client can customize based on policy language defining out-of-network benefits
- Proactive Patient Advocacy communication aimed at decreasing negative impact of balance billing
- Viant's methodologies are quantitative, objective, and applied consistently
- Viant's Facility Bill Review Service processes over $1 billion in claims annually
Summary
For clients looking for stronger savings performance on inpatient and outpatient out-of-network facility bills, Viant's Facility Bill Review Service is the solution of choice for many payers. Clients can experience significant cost savings and reduce out-of-network exposure while decreasing the negative impact of member balance billing.
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