A male worker crushed his left knee at work, resulting in a total knee replacement. The injured worker had multiple post-op complications that drove up costs on his case, including deep vein thrombosis (blood clots) in the injured leg, as well as exacerbations of existing health conditions: hypertension and diabetes type II. After his acute care treatment, he 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 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 Indiana to develop the care plan.
For this referral, Paradigm saved the client 27% below the bill review company’s total re-pricing; network discount savings of $503/day or a total of $4,522.
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