Developments in surgical technology and techniques have had a significant and positive impact on the field of orthopedic and spinal surgery in recent decades. For example, advanced implants enable surgeons to perform procedures that lead to better outcomes for patients with less risk of complication and shorter recovery periods. However, as surgical implant technology has become more complex, there has also been a corresponding increase in costs for payers, leading to new challenges in cost containment. 

This is exactly why Paradigm developed our proprietary cost management platform, Fusion by Paradigm^SM—to deliver transparency and pricing objectivity for workers’ compensation cases involving surgical implants. 

This data-driven platform leverages a process that consistently enables payers to help ensure appropriate care is provided on a cost-effective basis to injured workers. In a recent independent study, leading analytics firm Boston Strategic Partners found that Fusion by Paradigm achieves implant cost reduction that is 25 percentage points greater than industry outcomes. The report concluded that a key element of this success was Paradigm’s unique four-step adjudication process. 

Every individual case undergoes these four rigorous steps
Paradigm’s Fusion platform delivers savings across every implant-related cost category for the wide range of surgeries performed in work-related cases. With our innovative workflow, we can fully assess the true cost of surgical implants related to any type of case. 

1. Forensic assessment: The objective is to isolate and identify the individual implant items billed in otherwise open-ended “catchall” revenue codes in the bill submitted. In addition, our experts are carefully trained and experienced in identifying “creative” and unnecessary billing practices. 
2. Cost verification: We perform a thorough implant cost comparison against our Fusion database. This system is built on more than 10 years of data and hundreds of thousands of individual lines to provide complete transparency for surgical implants.
3. Objective allowances: Using this true pricing data, we calculate a more accurate reimbursement recommendation, while accounting for all state guidelines. This step also significantly reduces many of the challenges with bill reconsideration loops and therefore shortens turnaround time for payers. 
4. Daily data update: Our database continuously integrates and reflects new cost data from each case it handles. This safeguards third-party administrators against the risk of paying providers based upon out-of-date cost information.

Paradigm’s distinct approach rebuilds the cost structure of every implant surgery case, from the ground up, based on thousands of data points we’ve collected over a decade. The final result is a reimbursement value that is verifiable and defensible.

Find out how we achieve the highest cost savings in the industry with our unparalleled, evidence-based approach by downloading Paradigm’s implant cost containment white paper—the market’s first and most comprehensive audit solution.