Healthcare costs in American have appreciated over 20% per year for decades. This is unsustainable for most Americans and businesses. What is driving these costs and can we curb them? Today, PPO network relationships with Providers and Hospitals reduce medical bills from the charged amount to a contracted rate. Do these contracts have any basis on procedural costs for care? What is the overall relationship between the cost of care, the amount billed by healthcare provider, and the amount paid? It turns out that these 3 numbers are very fluid and arbitrary, which encourages an upward drive in cost. Worst of all, when there is a dispute between the amount billed and the amount paid, the patient is stuck in the middle – responsible for the balance. This is called balance billing and it is one of the leading causes of bankruptcy in America.
Since we don’t go to the doctor to purchase a widget at an established market rate, the challenge that insurance carriers and consumers face is how to define what the market rate should be for delivering medical care treatment. If appealing to Quantum Meruit, an English common law term that means “to get paid what is fair/deserved”, who establishes that amount? And how do you get all parties to arrive at the same number?
The solution: WellRithms, with over 25 years of auditing medical bills and paying them at a fair price, determines the Quantum Meruit amount for medical services and guarantees its accuracy and fairness. If a Provider disagrees with the amount and elects to balance bill the patient, perhaps even threatening collections, WellRithms will indemnify both the Health Plan and the Patient. Through it’s Indemnity Captive Insurance Company, WellRithms is able to assume full financial and legal responsibility for that claim under dispute. This renders any balance billing or collections threats as ineffective and unenforceable.
No other company in the Healthcare Industry will assume medical debt as a means to resolve payment disputes. This allows Health Plans to pay providers fairly without risk of the financial or legal stresses that exist today during the provider dispute process. This cost containment savings can be used by the Plan to enrich their benefit offerings or offset any other unrelated operating costs.
WellRithms savings averages 75% off the billed amount nationally. Is a 75% reduction off the billed amount fair? That appears that the provider is getting the short end of the stick. To the contrary, the WellRithms Quantum Meruit amount is determined by looking that the Providers’ reported cost for each documented procedure and marking it up with a generous profit. Unfortunately, WellRithms regularly identifies items marked up and billed in excess of 100 times the provider’s cost. No other industry benefits from such a markup.
On a recent bill, the drug Prilosec, an acid reflux over the counter drug that costs $0.72 per dose, was billed at 800 times cost and reimbursed by the PPO network with a 17% discount off the billed amount. Do the math. Did the PPO network contain the Health Plan’s costs?
In contrast to WellRithms’ Quantum Meruit approach, PPO networks generally negotiate contracts by using the Providers’ billed amount as the basis for negotiations. If billed amounts are arbitrary at the forefront, any negotiated reductions are arbitrary as well. As a result, provider contracted rates are biased towards Provider profits.
Healthcare spend is complicated. Determining the right price requires expertise in 1) the medical procedures, and 2) medical billing, removing fraudulent billing tricks, errors, egregious billed amounts. WellRithms has designed the technology to automate this process, flagging any complexities for manual Physician Review when necessary. As such, WellRithms is able to process over 100,000 claims an hour. Claims that are processed using the WellRithms technology will be cleaned of any errors, provider tricks, and inflated charges. The recommended payment amount is guaranteed and indemnified through its Captive.
As such, WellRithms is actively disrupting the healthcare payment process, one patient at a time. We cannot sit back and wait for congress to move the needle on Healthcare inflation. Plans must be more active and fiduciarily responsible with their money without compromising the benefits offered to their employees. WellRithms allows generous benefit plans and fair reimbursement to providers. A true win-win that is only possible in this generation of technological advancements, as architected by Physicians who have practiced medicine for multiple generations.