UCR Facility Repricing Services

The Issue
In response to customer requests for greater access to quality providers, payers continue to expand their HMO and PPO provider networks. In spite of this, however, many payers still experience significant out-of-network hospital claim volume that contributes to escalating medical costs and price pressures. Payers are therefore challenged to reduce these costs, while striving to maintain quality care for their members.

The Solution
Viant offers two solutions to help reduce facility medical claim costs. After a claim is submitted but before it is paid, Viant 'reprices' the claim to the usual and customary value. All inpatient facility bills are reviewed at the revenue code level utilizing the hospital's own cost data. A three-tiered methodology is used to evaluate outpatient bills. Each supports benefit plan language, which states that medically necessary goods and services consumed will be paid at the lesser of the usual, customary or reasonable charge. And, a proactive ‘Patient Advocacy’ defuses potential balance billing of the member.

Value Points  

• Average discount rates range from 23% to 36% depending on service mix
• Average success rates range from 76% to 82%
• The average dollar savings equates to approximately $6,024 per claim for inpatient claims and approximately $1,346 for outpatient claims
• Viant’s Repricing Services processes over $1 billion in claims annually
• Proactive 'Patient Advocacy' communication to defuse potential balance billing

How It Works
Inpatient Facility Bill Repricing (IPR)
Through its proprietary Cost-to-Charge™ repricing methodology, Viant provides an effective and defensible cost containment vehicle that yields significant savings for payers on inpatient facility claims. Viant uses the national standard cost accounting method for hospitals as the basis to calculate a customary and reasonable reimbursement to hospitals for the goods and services provided to patients on an individual claim basis.

Outpatient Facility Bill Repricing (OPR)
Viant uses a three-tiered methodology to evaluate outpatient bills that assures consistent and defensible repricing of outpatient facility charges and that a claim is being paid at an appropriate level. OPR can reprice charges at each payer's pre-specified percentile on a local or national level. A payer using the OPR hierarchy can expect to see a significant increase in their savings on non-network claims.

Advantages

• Most aggressive pre-payment cost control option, with strong savings performance
• Standard turnaround time (complete claims): 1-4 business days
• Flexible: repricing parameters can be customized to match client benefit specifications and policy language
• All Viant repricing methods are quantitative, objective, applied consistently and defensible

Summary
For payers looking for strong savings performance on inpatient and outpatient facility bills, UCR Facility Repricing Services is the solution of choice. Using consistent and defensible repricing methodologies, payers experience significant cost savings that helps lower their out-of-network exposure while minimizing member abrasion.

To learn more about Viant’s UCR Facility Repricing services, call us today at 800.820.5824.