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
Contact us below to get started or email us at info@quantifyhealth.co
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The Problem
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High Cost Claims (hospital claims with a payable of over $100,000) today represent 15-30% of total healthcare spend
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Unfortunately, there can be a significant amount of overcharging happening in one of five main categories:
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Billing errors: E.g., the hospital bills for 48 hours of ventilator usage in a 24 hour period
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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
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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
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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
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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
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The Quantify Health Solution
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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%
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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
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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
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Last year we delivered total savings of over $160 million (average savings per claim of 23%)
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Our solution works for health plans (commercial, Medicare, Medicaid), stop-loss/ reinsurance carriers, captives, and self-funded employers
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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
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We deliver average savings of 23% on high cost claims and implants
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Our reviews are performed by nurse practitioners and physicians with expertise in specific areas such as oncology, neonatal, transplants, etc.
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Forensic review includes a deep analysis of medical records, which takes tens of hours
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We build an incredibly detailed 10-30 page report with strong supporting medical evidence
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Once the claim is paid, we proactively reach out to hospitals to address pushback/ appeals
Getting started
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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
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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
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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)