Based on Medicare data from more than 30 million discharge summaries throughout the US, payers can now direct their members to the highest quality care possible at the best possible price, thus achieving additional indirect cost containment.
All the data used in Care Finder are reported by the healthcare providers themselves to the Centers for Medicare and Medicaid Services (CMS).
Care Finder allows users to determine reserves while always focusing on quality in care. It has a multiple use, as outlined below:
- IPMI/PMI insurers – determine up-front approval by the payer, who now has a tool at their disposal that determines treatment options based on a Cost and Quality Ranking (CQR)
- Travel insurance cases – if contacted early in the process, an Alarm Center can steer the member to the best possible facility based on the CQR. In cases where the member is already admitted to a hospital, a quick score card can be called up on the facility, enabling the decision maker to determine if moving the member to a better quality, and in most cases cheaper, facility that would be in the member’s best interests
- Medical tourism – in connection with IPMI, as well as on a self-payer basis, members can be directed to the best possible facility sorted out by type of treatment and on the CQR
- A tool for price comparison.
Example of a case study from the GCC
The following case study illustrates how Care Finder works for patients out of the GCC or other locations from around the globe.
Step one: Penfield is contacted by the payer – whether insurance or governmental – regarding treatment of a stage-one kidney cancer case.
Step two: based on the member’s medical record, Penfield suggests the best possible treatment facility in the US, based on a comparison between Category A CQR hospitals specialising in treatment of Kidney cancer.
M D Anderson was chosen by client as they treat the highest number cases and show the lowest estimated charges. The client has already saved up-front cost just by using the Care Finder, without sacrificing quality – all three hospitals in this comparison are at the very top of the US hospitals and specialise in this specific procedure (Clinical Category – Cancer Care / Kidney and Urinary Tumor procedures).
It should be noted that the cost illustrated above is limited to the procedure chosen. It does, however, represent the full cost of the member’s stay. A pre-negotiated rate of reimbursement can be established prior to services being rendered resulting in even higher savings.
Step three: having chosen the facility, the client can now choose the best surgeon for the procedure.
In this specific case, a physician specialising in urology and surgical oncology with 33 years of experience was chosen based on his success rate in this specific kidney procedure having conducted more than 170 successful surgeries.
Step four: concierge services such as transport, meet and greet at the airport, hotel arrangements for accompanying relatives and hospital admission are arranged by Penfield upon request of the client.
Step five: during admission, Penfield monitors the case in liaison with the hospital, payer and patient, ensuring the entire process goes as smoothly as possible.
Step six: upon discharge and being fit to fly, the member and family are now transported back to the UAE.
Step seven: upon discharge, the final invoice is received by Penfield, which now starts the second phase of cost containment by negotiating directly with the provider, which typically results in an additional average saving of 52 per cent of the presented invoice.
All saving deals are documented as ‘sign off’ deals, which in practical terms means no future hassle of any kind – i.e., no legal battles etc.
Penfield also provides discounted prescribed medicine to the member in question, adding to overall savings. Our pharmacy network consists of over 60,000 pharmacies throughout the US. The network includes high-cost drugs.
Step eight: invoice is settled with Penfield.