For Surgical Implant Bill Review, Curated Data Makes a Difference

WorkCompWire

A Q&A with Gus Tschaar, Chief Bill Review Officer, Paradigm

Innovation in surgical implant technology undoubtedly benefits injured workers, but it also means increased billing complexity for payers. This, in turn, creates ongoing challenges while trying to manage dozens of details for injured worker cases.

Paradigm’s surgical implant cost management platform is designed to deliver clarity and ease, not challenges, through an unparalleled data library and an adjudication process built on accurate pricing.

What sets Paradigm’s platform apart is the unique library of implant cost data, curated by experts with decades of industry-specific knowledge in both workers’ compensation and surgical implants. We sat down with Gus Tschaar, Chief Bill Review Officer for Paradigm, who has over 20 years of domain expertise in the surgical implant industry and is one of the founding creators of the platform, for more insights into what sets Paradigm’s proprietary platform apart and how it achieves industry-leading results.

What is your background and how did you enter into the area of surgical implant bill review?
After graduating from college, I entered into medical device sales, selling products ranging from anesthesia platform monitoring equipment to spinal fusion devices. I worked in that part of the industry for over 10 years, and that’s where I began to develop a deep knowledge of both surgical devices and the market dynamics of the medical device industry. I believe having a background in this sector helped me understand many of the practices and behaviors payers see in workers’ compensation surgical billing.

How did you come to Paradigm, and what was your role in developing the platform?
I was one of the founders of a company that would eventually provide the foundation for Paradigm’s implant cost management program. By previously specializing in implantable device acquisition and billing for providers, I was able to develop a broad and unique understanding of the intricate market dynamics. I leveraged the perspective I gained from that experience and created the foundation for a new company focused exclusively on containing implantable device spend for the workers’ compensation payer community. The culmination of unique legacy experiences in this often opaque market evolved into what is now the core of Paradigm’s implantable device bill review platform.

Essentially, it was a 180-degree rotation from my prior experience. Instead of purchasing and billing devices out to the payer community, we turned the model around to audit the bills coming in from the providers. My main role has always been highly hands-on and technical, with a majority of my time spent carefully analyzing surgical implant bills. The driving goal in developing and refining our platform has always been to deliver pricing clarity for payers based on historical data and accurate manufacturer pricing.

Can you talk about what differentiates the Paradigm surgical implant review platform from other industry approaches?
Our approach has been honed for more than a decade and is industry-specific. It’s been essentially home-grown from the beginning, with many of the same staff still curating the platform today. Workers’ compensation is managed at the state level and often there are no guidelines for implant billing. The critical challenge for claims professionals managing these cases is the struggle to determine accurate reimbursement, as very often they only have data from the provider to justify the cost.

For surgical devices, the billing is very complex, with many items that typically go into a given procedure. Paradigm’s in-house expertise with prior experience on the provider side—actually purchasing the implants and billing them to payers—helped us focus on building a database that could deliver actionable information. This leads to a very deep, forensic intelligence of implant devices and their corresponding billing practices.

Paradigm’s approach is based on accurate industry data that’s defensible. Any bill review platform can have a universal database with many lines of data. Oftentimes that data doesn’t reflect the actual cost of the device from the manufacturer. Or there may be devices that aren’t specific to the implant procedure that we see in workers’ compensation. If payers are basing bill review on this type of unchecked data, a payer probably won’t benefit from the cost savings that are often produced by Fusion.

Over the years, we’ve been able to catalog tens of thousands of cases that have been run through our program.

Paradigm’s database is highly curated, and we’re extremely vigilant in keeping the core operational integrity of our platform intact.

What are examples of the types of billing practices that payers encounter, and how does Paradigm handle them?
Payers need help identifying any practices at the provider or distributor level, where there can be egregious implant markup or billing errors. At a basic level, bills need to be audited to ensure that what is listed on the invoice was actually used during the surgical procedure. Extreme cases can involve distributors re-labeling implants or engaging in what amounts to double billing.

An intelligent database and secure process should be able to catch inaccuracies or erroneous billing practices and recategorize those charges correctly.

Find out more about Paradigm’s Surgical Implant Cost Management solution and how Paradigm achieves the highest cost savings in the industry.

Full article on workcompwire.com: For Surgical Implant Bill Review, Curated Data Makes a Difference