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Quantify Health offers a forensic review of high cost claims, and we have historically delivered average savings of 23% per claim

Works for health plans (commercial, Medicare, Medicaid), TPAs, stop loss carriers, reinsurers, and self-funded employers

Shared-savings model where the client keeps 70% of the savings and we get 30% – no other costs involved

Clients include a top 5 health insurance carrier, two major health plans with 1M+ lives each, five of the top 25 reinsurers, and two of the top 20 stop loss carriers; we are also a preferred vendor of ACAP

Last year we delivered $160 million+ in savings

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The Problem

  • High Cost Claims (hospital claims with a payable of over $100,000) today represent 15-30% of total healthcare spend

  • Unfortunately, there can be a significant amount of overcharging happening in one of five main categories:

    • Billing errors: E.g., the hospital bills for 48 hours of ventilator usage in a 24 hour period​

    • Charge unbundling: E.g., the hospital bills separately for patient monitoring, even though the cost is actually included in the cost of room and board

    • Mismatch of service and billing: E.g., even after a patient has been moved from trauma ICU to regular ICU, the hospital continues to bill at the higher trauma ICU rate

    • Experimental and investigational: E.g., the hospital bills for treatments that are not covered under the health plan and might be more expensive than other treatments

    • Hospital-acquired conditions: E.g. the hospital makes an error during a surgery and so has to take the patient back into the OR, but bills separately for both surgeries

The Quantify Health Solution

  • Our team of US-based physicians and nurse practitioners performs a forensic analysis of both the itemized charges and the medical records (which can take tens of hours), which delivers average savings of 23%

  • For health plans we can do this on both a pre-pay and post-pay basis - for TPAs and stop loss carriers, we only offer our service on a pre-pay basis

  • Contingent-based shared savings mode, where we charge 30% of the actual realized savings based on the difference between the original allowed amount and the repriced amount

  • Last year we delivered total savings of over $160 million (average savings per claim of 23%)

  • Our solution works for health plans (commercial, Medicare, Medicaid), stop-loss/ reinsurance carriers, captives, and self-funded employers

  • We are a preferred vendor for the Association of Community Health Plans - an association of 75+ health plans across the country


Preferred vendor

Five key differentiators

  •  We deliver average savings of 23% on high cost claims and implants

  • Our reviews are performed by nurse practitioners and physicians with expertise in specific areas such as oncology, neonatal, transplants, etc.

  • Forensic review includes a deep analysis of medical records, which takes tens of hours

  • We build an incredibly detailed 10-30 page report with strong supporting medical evidence

  • Once the claim is paid, we proactively reach out to hospitals to address pushback/ appeals

Getting started

  • For health plans/ stop loss carriers/ TPAs: We start with a free preliminary analysis of 3-5 claims and then run the full forensic review to deliver strong savings

  • For employers: We start with an opportunity analysis by requesting the last 12 months of claims data (no PHI) and come back with the savings potential

  • We would both sign a BAA (happy to sign your format once we review it) and our contract (which can be canceled at any time with a 30-day notice)

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