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SCALE Case Study:

Payer Strategy – Pediatrics

Client Profile

  • Size:
    15,000+ Providers
  • Location:
    10 States
  • Specialty:
    Pediatric

Services Deployed

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ASC Operational Strategy & Execution

Strategy Performance and Optimization

Program Development

Overview

SCALE Payer Strategy was engaged by a pediatric home service group facing deep reimbursement rate cuts.

  • The client is a leading independent children’s home health care agency for complex pediatric patients. The business has long-standing relationships with payers often seen solely as a DME provider, even though services are far more extensive.
  • Client faced ~30% rate decreases from primary payer in the state.
  • Client interested in transitioning towards a value-based care model.

Execution

  • Completed a market and payer competitive analysis of current states
  • Developed strategy to engage with payers and transition to a value-based care model.
  • Reimagined the limited identity of being a single service provider.
  • Guided client on building out and investing in care coordination services.
  • Executed payer outreach and strategy.

Results

  • As a result of payer discussions, revenue increases were unveiled that underwrite losses related to potential fee schedule reductions.
  • Strategy is currently evolving to fit the client’s other payer needs, and continued conversations.
  • Client was satisfied with initial payer strategy execution
  • We continue discussions with additional payers and Center for Medicare and Medicaid Innovation (CMMI) for impact to national program development.
  • To date, scheduled fee schedule reductions have been postponed.
  • There is a chance these cuts could be eliminated completely.
  • Executed a strategy to expand their care model improving their position for participation in a value-based care model.
  • Introduced and built relationships for the client at CMMI.

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SCALE Healthcare is based on the foundation of a singular focus – elevating management performance across healthcare services. We are focused on the entire suite of operational advisory and diligence services exclusively to healthcare service organizations, with local team presence across 10 states.

Unlike the many consulting firms that offer more narrow and often more impractical solutions borne of limited or very general expertise, we rely on our team of 75+ carefully selected senior operational healthcare experts to ensure we provide the most relevant and value added experience across the full range of management disciplines and clinical specialties that fall within healthcare services.

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