Challenge

A leading home- and community-based healthcare organization sought to optimize their medical cost savings and in-network provider penetration from their medical bill review provider. They turned to Sedgwick, their partner for workers’ compensation claims management, for an integrated solution.

Solution

Our inclusive analytics model uses network hierarchy to save the maximum on preferred provider organization bills. We leverage proprietary provider scores to build panels that identify high quality providers to optimize in-network penetration. Additionally, our experts have real-time access to information that allows them to efficiently review claims and validate whether services billed are compensable; if they are, we apply fee schedules and usual and customary rates. We also use clinical nurse review, out of network negotiations and specialty repricing solutions.

Results

In just nine months, Sedgwick has already saved our client an average of 14.2% in medical paid per claim while using the same exact bill review software as their previous partner. We have also increased the client’s in-network provider utilization. This approach not only continues to save the client money but it also ensures that medical bills are paid on time so injured workers get the right care and have a positive experience on their road to recovery.

Clients who use our integrated bill review services see a reduction in overall claims cost by 10-13%

14.2%

average savings on medical paid per claim

27:1

net return on investment for all states

82%+

of claimants are treated by in-network providers