REIMBURSEMENT BENCHMARKS BENEFITS Assess the competitiveness of your reimbursement rates Access benchmark data for your market Use intelligent data to negotiate effectively Develop market-based fee schedules Effectively compare inpatient and outpatient reimbursements FEATURES Uses data from MarketScan®, the largest and most trusted claims database in the industry Provides estimates of reimbursement rates by procedure type and MS-DRG Evaluates median and average reimbursement rates Includes low, medium, and high estimates at the 25th, 50th, and 75th percentiles Provides estimates as low as the Core Based Statistical Area (CBSA) Actionable Information for Contract Negotiation Hospitals are struggling with decreasing margins and looking for increased revenue opportunities. Negotiating payer contracts with competitive rates and defensible pricing is a key driver in improving rates and decreasing risk. However, determining the value of a contract without specific, detailed reimbursement benchmarks can feel like a guessing game and can present significant risks and pricing blind spots. Many hospitals are hungry for information that can help them understand exactly where their rates stand compared to the market, so they can negotiate effectively. They need answers to questions, including: §§ How do my reimbursement rates compare to others’ within my market? §§ Are there specific areas where my rates are significantly out of line with market norms? §§ How can I mitigate risk and defend my pricing to payers? §§ What are the expected reimbursements on a new line of business? §§ How do I create a competitive, realistic fee schedule? Reimbursement Benchmarks Backed by the Industry’s Largest Database Leveraging the Truven Health MarketScan® database, the largest and most trusted claims database in the industry, Reimbursement Benchmarks deliver highly specific reimbursement estimates that contract negotiators can use to manage rates and defend pricing. Reimbursement Benchmarks are based on a proprietary methodology providing estimates of reimbursement rates, by Current Procedural Terminology (CPT) code, the Healthcare Common Procedure Coding System (HCPCS) and Medicare Severity Diagnosis Related Groups (MS-DRG), which consider cost characteristics for a specific geography with servicespecific nationwide cost information. These estimates are provided at the Core Based Statistical Area (CBSA), making the information specific enough to identify and support target actions contract negotiators can take to improve their contracts. Service Spotlight Reimbursement Benchmarks Examples The below figures display some of the payment estimation capabilities of Reimbursement Benchmarks. FIGURE 1: Using Reimbursement Benchmarks to Estimate for Depressive Neuroses DRG in the State of Minnesota Year Geography Parent/Child MS_DRG 2011 North Central Minnesota 881: Depressive Neuroses Ability to aggregate information at the state level Professional Calculations Professional Net Payment Model Estimate Lower 95% Upper 95% Low Estimate High Estimate $447 $436 $458 $275 $725 Professional Gross Payment $512 $509 $534 $321 $847 Professional Eligible Charge $645 $629 $661 $397 $1,047 $138 $135 $141 $84 $227 Professional Net Payment Per Diem Professional Gross Payment Per Diem $161 $157 $164 $98 $265 Professional Eligible Charge Per Diem $199 $194 $204 $121 $327 $9,468 Facility Calculations Facility Net Payment $5,459 $5,329 $5,593 $3,148 Facility Gross Payment $6,387 $6,242 $6,536 $3,683 $11,077 Facility Eligible Charge $8,612 $8,406 $8,823 $4,966 $14,936 Facility Net Payment Per Diem $1,524 $1,490 $1,558 $1,004 $2,312 Facility Gross Payment Per Diem $1,783 $1,745 $1,821 $1,175 $2,705 Facility Eligible Charge Per Diem $2,404 $2,351 $2,458 $1,584 $3,647 FIGURE 2: Using Reimbursement Benchmarks to Estimate for CPT 00100: Salivary Gland Anesthesia in the Dixon, IL CBSA Year Hospital OP Geography Parent/Child CPT/HCPCS and resolved modifiers 2011 Ambulatory Surgical Center Illinois 19940: Dixon, IL 00100: Anesth, Salivary Gland Default Break out estimates by site of service Professional Calculations Professional Net Payment CBSA-level data translates to actionable information Model Estimate Lower 95% $663 $651 Ability to view estimate for HCPCS with or without modifiers Upper 95% Low Estimate High Estimate $674 $484 $907 Professional Gross Payment $782 $769 $796 $571 $1,071 Professional Eligible Charge $1,309 $1,287 $1,332 $957 $1,793 Facility Net Payment $831 $704 $981 $522 $1,324 Facility Gross Payment $938 $795 $1,107 $589 $1,495 Facility Eligible Charge $956 $810 $1,128 $600 $1,523 Facility Calculations FOR MORE INFORMATION Send us an email at [email protected] or visit truvenhealth.com ABOUT TRUVEN HEALTH ANALYTICS Truven Health Analytics delivers unbiased information, analytic tools, benchmarks, and services to the healthcare industry. Hospitals, government agencies, employers, health plans, clinicians, pharmaceutical, and medical device companies have relied on us for more than 30 years. We combine our deep clinical, financial, and healthcare management expertise with innovative technology platforms and information assets to make healthcare better by collaborating with our customers to uncover and realize opportunities for improving quality, efficiency, and outcomes. With more than 2,000 employees globally, we have major offices in Ann Arbor, Mich.; Chicago; and Denver. Advantage Suite, Micromedex, ActionOI, MarketScan, and 100 Top Hospitals are registered trademarks or trademarks of Truven Health Analytics. truvenhealth.com | 1.800.366.7526 ©2013 Truven Health Analytics Inc. All rights reserved. All other product names used herein are trademarks of their respective owners. HOSP 13351 1213
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