A female worker fractured her right femur and suffered knee contusions secondary to a fall at work. The injured worker had multiple post-op complications that had the potential to escalate treatment costs, including high pain management needs and obesity. After her acute care treatment, she was referred to Paradigm for an inpatient rehabilitation provider.
Our interdisciplinary clinical review team started by compiling an extensive health history of the injured worker. We then consulted our own database of payment comparables for other providers, both locally and nationally, and reviewed Centers for Medicare and Medicaid Services (CMS) rates for case mix group reimbursement to ensure our plan created the best care and the best value.
We proposed—and the provider accepted—an all-inclusive day rate with a minimum savings guarantee (from total provider billed charges). We worked closely with the inpatient rehab center in Wisconsin to develop the care plan.
For this referral, Paradigm saved the client 20% below the client’s bill review company’s total re-pricing; network discount savings of $147/day or a total $8,368 for a 57-day stay.
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