Highlighting Unique Protocols to Achieve Premium Reimbursement: Specialized Surgical Practice

Situation

A specialized surgical practice in New Jersey, focused on a specific condition with a high recurrence rate, had developed a highly-effective surgical protocol. The practice was primarily operating on an out-of-network (“OON”) basis due to low in-network reimbursement rates for its key code.

Challenge

New Jersey “market” rates are typically 100% of CMS – and to get there often takes significant negotiation. This practice was no exception. Rate offers at or below CMS did not reflect the value of their specialized expertise, reduced recurrence rates, and the cost savings resulting from fewer courses of care.

The practice was receiving approximately 400% of CMS rates OON, but in addition to travel and hotel costs, using OON benefits limited the addressable market. While willing to accept a lower rate, the practice had been unable to secure acceptable offers.

Approach

Tribunus Health emphasized the practice’s unique, highly-successful surgical protocol and its proven ability to significantly reduce recurrence rates compared to standard procedures. This was supported by data demonstrating that the practice’s success rate exceeded 96%, with a revisional surgery rate of only 3.4%, compared to 46% recurrence for its commonly-practiced alternative. Tribunus Health tied these outcomes figures to the total cost of care to illustrate $40,000 in savings per surgical event.

Solution

Tribunus Health engaged the payer, presenting the practice’s value proposition centered on cost savings, stemming from a) the value inherent to the provider’s superior outcomes, and b) potential savings relative to the average OON rate.

The ultimate agreement was structured with higher reimbursement (350% of CMS) for the practice’s highest-volume surgical codes and a lower rate (150% of CMS) for other services.

Outcome

By agreeing to lower-than-OON – but still premium – in-network rate, the practice’s patients were able to utilize their in-network benefits, the payer’s costs were reduced on both a preventive basis and relative to OON spending and the practice benefited from higher revenue quality and patient throughput.