Optimizing savings levers

Optimizing savings levers

All savings levers matter for all payment types in NICU populations

We focus on managing the major variables that impact outcomes regardless of contract method or type. 

NICU claims cost factors

Solving the inherent economic problem of low-volume, high-cost NICU cases

NICU claims make up a relatively small percentage of a plan’s total claim volume but consistently represent the top 1% of costs. These cases are also very complex. UM and CM are critical to improving outcomes for all. Our team and our technology are dedicated exclusively to improving NICU population health and reducing total case costs. 

At ProgenyHealth, NICU UM and CM is all we do, every day, across the country. We’ve managed over 60,000 NICU cases to-date – more than most plans see in several decades.

How to appropriately apply clinical criteria to ensure accurate billing

Our evidence-based methodology and interventions help rebalance the billing level distribution to less costly days. NICU bed levels are billed using Revenue Codes 172, 173 and 174.  The 174 days are most intensive and costly. As a NICU baby clinically improves and progresses towards discharge, the days in most facilities should become less costly. 

With continuous review and oversight, we are able to positively impact the Revenue Code mix, rebalancing the distribution to accurately reflect the intensity of services provided to the infant. The result is less costly NICU days for ProgenyHealth plan partners.

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 Executive Officer of Health Alliance Plan
Progeny has been an outstanding partner. Their clinical expertise in the NICU arena has helped us to manage the care of these infants effectively, and they are completely committed to identifying and addressing the social determinants of health often found in this fragile population.
- Marge Angello, AmeriHealth Caritas’ Market President
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

What is the average length of a NICU stay and how to manage it?

Average length-of-stay (ALOS) is actually a stepping stone to savings for all payment methodologies. The national average for NICU length-of-stay has consistently risen and is now at approximately 20 days, but not for our plan customers. ProgenyHealth’s program improves NICU length-of-stay from almost any starting point. We consistently bring ALOS down, and keep it down, across the board.

Our comprehensive, integrated NICU UM and CM helps these infants come home healthy and at the right time.

ProgenyHealth NICU ALOS

How to reduce NICU infant hospital readmissions / ER visits

Up to 70% of readmissions occur 30+ days after discharge. And most NICU babies who present at the ER are likely to be admitted. ProgenyHealth’s approach reduces readmission rates by up to 50%.  In a study of 3,529 non-Progeny and 1,312 Progeny commercial NICU babies in the same market, our solution helped drive a 71% reduction in ER visits.

It’s all about going above and beyond via our extended CM model — a 24/7 virtual safety net for the baby and family in the first year of life. Our CM team has both a nationwide knowledge-set and access to local community resources needed to provide the right support to the families, right when they need it most.

Learn how we help ensure payment validation & assurance for your NICU claims.

Get our latest insights on NICU population health management