WellRithms mitigates financial risk associated with healthcare claims by delivering integrated Sustainable Claims Pricing (SCP) solutions to the self-funded industry. Using data-driven methodology, backed by medical and legal expertise, WellRithms reprices claims accurately, fairly, and reasonably. WellRithms solutions eliminate the need for networks and makes healthcare more affordable.
WellRithms repricing is not an arbitrary percentage of Medicare or other benchmarks. Rather, our methodology is based on the common law principal of quantum meruit: as much as deserved. WellRithms determines a fair and reasonable reimbursement rate by analyzing what the provider generally accepts from all payer sources including commercial, federal, and private payers.
In addition, the core of our methodology includes a thorough audit of the claim using standard billing and coding edits followed by a line-by-line, physician-led review to determine that the bill accurately reflects the medical services provided and fair reimbursement that is legally defensible.
Sustainable Claims Pricing (SCP)
Out-of-network providers commonly charge patients a higher rate and often an excessive amount for medical services rendered.
Accurate medical bill review requires medical understanding and interpretive expertise. The WellRithms team of experts provides in depth analysis to ensure the highest level of accuracy by identifying duplicate services, excessive charges, coding errors, and even abusive billing practices.
WellRithms delivers physician-led medical bill review using reasonable and customary pricing that reduces the liability of these high-dollar out-of-network claims for payers and patients.
Catastrophic medical bills represent a complex diagnosis which involves chronic, ongoing treatments. Treatments for these conditions are listed as essential benefits under the Affordable Care Act (ACA). Such diagnoses include, but are not limited to, organ transplants, orthopedic and pain procedures, complex cancer care, renal failure, congenital anomalies, congestive heart failure, and short gestation/low birth weight.
WellRithms works directly with employers and associated administrations to limit financial liability by reviewing and repricing this category of high-dollar claims. Careful bill review on a line-by-line basis assures the right price to achieve maximum savings.
In-Network Bill Review Audit
Even in network bills have been found to contain significant mistakes such as undocumented medical services, coding errors, and egregious charges.
When plan language and provider contracts allow, WellRithms reviews in-network claims to determine medical and coding correctness and appropriateness to find additional savings for self-funded and other qualified health plans.
Sustainable Claims Pricing (SCP)
for Self-Funded Health Plans
Healthcare costs and insurance premiums continue to rise at an unsustainable rate. More and more employers are moving away from fully-insured health plans to self-funded health plans in an effort to control costs and still provide employees with quality health care coverage.
WellRithms works with administrative experts to provide high quality health benefits at an affordable price. With seasoned brokers, third party administrators, stop loss providers, and WellRithms, employers will reduce health care premiums and spending and maximize savings which immediately impacts the bottom line.
WellRithms combines full service technology, medical expertise, and legal acumen to provide fair and appropriate reimbursement. We DO NOT use a multiple of Medicare. Rather, WellRithms methodology produces a reasonable and customary price that is backed by case law.
The healthcare benefits journey begins with the plan, is extended to the member, moves to the provider, and returns to the plan. We believe claims care is equally important as patient care. For this reason the healthcare industry is only sustainable when both patient and claims are cared for with excellence, consistency, and scrutiny in each phase.
WellRithms stands with the plan and champions consumer healthcare literacy and support when providers push back with balance bills. You are not alone with WellRithms.
Usual, Customary, and Reasonable (UC&R)
Sometimes disputes arise over the right price for medical services rendered with complex claims and a resolution anchor is needed.
The physician-led WellRithms team will provide line by line bill review and repricing to produce a UC&R determination anchor to facilitate a dispute resolution.