A male industrial worker had a soft tissue foot injury, which was adversely affected by clinical complications of diabetes mellitus, causing gangrene at the injury site and requiring amputation. He underwent initial transmetatarsal amputation with a 60-day follow-up to evaluate a possible below-the-knee amputation. Paradigm received the referral at the completion of patient’s acute care treatment course and after inpatient rehabilitation hospital was selected.
Our interdisciplinary clinical review team reviewed the associate’s health history and prior plan of care. We also consulted our own database of services and allowances for other providers in the area to get a baseline comparison for equivalent alternative care settings. This included skilled nursing facilities, as well as Centers for Medicare and Medicaid (CMS) rates for inpatient rehab hospital case mix group reimbursement.
Working with a rehabilitation hospital in Georgia, Paradigm negotiated a prospective rate. Before finalizing the rate, Paradigm activated a second opinion review of the case to make sure we’d been as comprehensive as possible.
This prospective referral achieved savings of 13.6% below the bill review company’s network discount savings, as well as its tentatively negotiated rate for its catastrophic claims unit. These additional savings totaled $2,700 for a 17-day stay. We also negotiated the associate’s per diem total charges to $16,150, resulting in additional savings.
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