Build versus Buy

Build versus Buy

What is the business case for outsourcing NICU Utilization Management and Case Management?

Outsourcing for Payers

Health plans excel at managing benefits and the member experience, but to thrive in an increasingly efficient market, they must leverage economies of scale and expertise. Complex newborn cases present a critical opportunity to leverage enhanced efficiencies and specialized knowledge available from outsourcing.

Today, nearly 90 percent of payers seek service partners who can improve specialized care, streamline administrative processes, and expand access to care coordination. Year over year, business process outsourcing by health plans has grown 22 percent1. As a health plan is making a decision to build versus buy, when it comes to specialization – especially NICU Care Management, buy is the more efficient and impactful choice.

The NICU Challenge for PAYERS

The low-volume/high-cost nature of NICU cases creates a unique challenge for payers. Insufficient NICU case volume makes it prohibitive to develop in-house programs and field the specialized teams required to impact NICU outcomes and total cost of care.

The development costs and overhead explain why health plans apply a hands-off approach to NICU cases. They typically authorize most of what is presented and automatically approve the first 30 days of a baby’s NICU stay. Even with a step-by-step approach that authorizes the first seven days, successive approvals grow to 30 days or more.

Approvals Timing Challenge

Building the infrastructure and fielding an experienced team takes time. Developing an accredited program can take months – often up to 12 months or more.

In-house Case Management programs are also often ineffective (waiting until after discharge to start), limited in scope (avoiding SDoH issues), and often only apply Case Management to the most complex cases.

ProgenyHealth addresses the inefficiencies in conventional NICU Care Management by proactively engaging providers and families early and often with the support of a proven NICU management platform.

The NICU Challenge for EMPLOYERS

Self-insured employers face similar challenges from high-cost claims and lost productivity related to complex NICU cases. Companies in tech and knowledge industries are particularly vulnerable to catastrophic NICU claims due to their younger and more female-focused demographics.

ProgenyHealth works through Administrative Services Only (ASOs) and third-party administrators (TPAs) to deliver the benefits of outsourced NICU Care Management without any overhead or headaches. We support TPA and ASO administrators to integrate NICU Care Management into the health plan design to address the needs of employees. Importantly, we provide the tools to create a custom plan design that attracts and retains the most talented employees while mitigating the costs of NICU claims from premature births.

Implementing a NICU Management Infrastructure

Standardized care is the key to managing complex newborn cases. Only ProgenyHealth has developed an integrated NICU Utilization Management and Case Management platform that standardizes care, supports caregivers, and manages the NICU cost curve through its management of savings levers.

Our NICU infrastructure is not easily duplicated. Built by a specialized team with years of NICU expertise and knowledge of state-specific requirements, health plans and employers benefit from the years of experience and the millions of data points utilized as a part of this proprietary platform. Our implementation team can adapt our solution to your operations and workflows for fast, efficient onboarding.

ProgenyHealth UM & CM

Proprietary NICU Technology is the Key

ProgenyHealth’s Baby Trax® platform uses real-time predictive and prescriptive modeling drawn from over 70,000 NICU cases to implement 17 years of best practices in medically complex infant care. The technology creates a digital footprint of the patient’s journey to prompt the NICU team at each decision point. Predictive analytics and diagnostic triggers drive structured, yet individually tailored, case management plans. The result is seamless care coordination, compliance, and analytics that inform action and manage utilization.

Real Results from Outsourced Expertise

ProgenyHealth’s comprehensive NICU solution reduces inpatient costs, physician fees, ED visits, and readmissions. By outsourcing a low-volume/high-cost, yet critical segment of your member claims, our partners achieve a consistent cost-savings ROI of 2:1 or better and ensure payment integrity.

Best of all, by outsourcing care coordination and case management to a dedicated partner like ProgenyHealth, payers can expand their capabilities and capacity without stressing in-house resources.

ProgenyHealth 2:1 ROI

Contact us now and let’s discuss how much you could save in NICU claims costs.

[1] Black Book’s survey 5,400 health plan BPO users collected from Q3 2014 to Q1 2015

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Ensure payment integrity for NICU claims
Our medical management team worked closely with the experts at ProgenyHealth to deploy this integrated and very effective program. Their singular focus on NICU babies and their families was crucial to the program’s success, and especially vital in building a collaborative relationship with our providers. We’re very pleased with the outcomes of this initiative and the role it plays in our ongoing efforts to help members most at risk of developing serious chronic conditions.
- Dr. Michael Genord
Chief Medical Officer of Health Alliance Plan
The value and benefit of ProgenyHealth to our members’ health and satisfaction alone is worth the cost.
- Health Plan CEO
ProgenyHealth has helped to reduce our ALOS, reduce outlier days, and keep our readmission rates low. Testimonials from our members are full of praise.
- Health Plan CMO