PayerFusion Perspectives: Fixing a Flawed System

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April 1st, 2012

The traditional approach no longer works; creativity and diligence are key to success today.

Industry experts continue to conclude that standard short-term measures to address rising costs in the US health care environment are not working.  This is obvious to all of us; otherwise, why such a big emphasis, effort, and diligence to produce health care reform.  We are all aware of what our country has gone through to even get reform begun and the big controversy that still surrounds the subject and its initiatives.

We must support the changes that are about accountability.   We must support payment reforms rather than reduction based on charges that are commonly known as “cost containment.”  We must support steps that will focus on accountability and responsibility for better systems that bend the cost curve and produce a high-value health care system so urgently needed. And we must do all this without jeopardizing the access to care that is important to Americans.

To slow health care spending we must include a comprehensive strategy to increase accountability and support for lowering cost and increasing quality.  Reductions based on charges are often insignificant when inflation is factored in.  Eliminating reduction based on charges really has no impact on the cost per claim, whether paid directly by the consumer, insurance company, or government plan.

There is no evidence suggesting that greater mark up in charges equates to better outcomes for the patient and providers.

We must place more emphasis on reimbursement based on cost plus reimbursement methodologies.  In processes, this approach will make the high fee-for-service, high charge-driven models obsolete.  The result of this transition will be Systems that make health care affordable and providers profitable.

Traditional provider network entry is determined by the willingness of a provider to accept a discounted “piecemeal” perspective, the quality practice is not monitored nor rated in any meaningful way relating to its impact on costs.   As a result traditional PPO design has failed to demonstrate any meaningful impact on costs.

It is a challenging task to change the system.  More than health care reform, we are embarking in reimbursement reform that looks at quality, outcome and fair payment for all parties.  Supported by care management, predictive modeling,  and knowledge of what works and doesn’t make PayerFusion equipped to address fair pricing for all constituents.

PayerFusion moves beyond the traditional PPO design to a network design that is based on quality criteria and episode-based costs.   Our tiered provider initiative qualifies every provider through its design.   Our approach is not “cost containment” but rather proper reimbursement for less liability to the patient, the consumer, and the insurance.

Quality and value are the two most important factors driving outcomes. They are guiding markers along the new path of success – for both providers and patients.

In every claim that’s processed for payment, tech-driven informatics give clients fair reimbursement to providers with analyzation for payment validity.  Our cost plus system supported by our unique technology and industry analytics continue to make a true change for our clients in the achievement of fair reimbursement in an imperfect market.

Our solutions account for current and future changes so that, rather than reacting, we’re ready.

G. Chernys,  President & CEO