Matt Lefkowitz
Director of Customer Strategy & Implementation
At Kubera, we build analytics tools to help healthcare providers negotiate more reasonable prices and get paid what they're owed.
Because healthcare is so complex, explaining how all the pieces fit together is best compared to making a nice dinner
Once you have all your ingredients, it’s time to start cooking.
1. Olive Oil → Chargemaster
First, let’s make sure you have your olive oil. Sure, you’d probably be fine without it. But when you need it, you really need it and it helps to avoid a mess. For our purposes, that’s the chargemaster. Most healthcare services don’t reimburse according to the chargemaster, but the CDM is always there and factoring into the formula. For example, Lesser of language is incredibly common in contracts, which means that reimbursement is calculated as the lesser of the contracted rate or the chargemaster price. It usually doesn’t matter, until it does.
2. Vegetables → Fee Schedules
Now for the vegetables of the dish, your fee schedules. Toss in some broccoli, that’s your inpatient Medicare DRG-based hospital pricing. Add a little asparagus, roughly the vegetable equivalent of Medicare outpatient pricing, built on HCPCS and OPPS logic. Finally, don't forget the mushrooms, the ones you have to hunt for, much like elusive payor fee schedules. We help our customers identify these fee schedule gaps and get them fixed. The list goes on and on. There is an endless pool of vegetables, or fee schedules, to choose from. Let’s throw them all in our pan.
3. The Recipe → Contracts
An amateur chef like myself trying to prepare a new dish without a recipe is bound to go wrong. A recipe carries specific instructions, three tablespoons of salt, 40 minutes in the oven. A contract works the same way, one service reimburses at $40 per visit, another at 225% of the payor outpatient fee schedule. A contract is to analytics what a recipe is to cooking. Necessary, but useless without the right infrastructure around it. So much of what actually prices a claim lives outside the contract itself, external fee schedules, advanced pricing rules, clinical guidelines, multiple procedure reimbursement, policies and more.
3. The Recipe → Contracts
An amateur chef like myself trying to prepare a new dish without a recipe is bound to go wrong. A recipe carries specific instructions, three tablespoons of salt, 40 minutes in the oven. A contract works the same way, one service reimburses at $40 per visit, another at 225% of the payor outpatient fee schedule. A contract is to analytics what a recipe is to cooking. Necessary, but useless without the right infrastructure around it. So much of what actually prices a claim lives outside the contract itself, external fee schedules, advanced pricing rules, clinical guidelines, multiple procedure reimbursement, policies and more.
4. The Steak → Claims Data
A steak dinner is not complete without a steak. Kubera’s analytics tooling supporting contract modeling and underpayments analytics is not complete without claims data. Our version of medium rare is actually a claims dataset that contains both Electronic Medical Record data (EMR data) and clearinghouse EDI data (835/837 data). We need both because a claim priced on one alone has blind spots. The 835/837 lacks paper remits and the EMR data loses line payment detail. The combined 835/837 and EMR data is a perfectly cooked steak.
5. The Chef → Kubera
A chef takes all of the ingredients, the recipe, and his own intuition to produce a delicious meal. Kubera analytics works similarly, taking contracts, fee schedules, claims, and a proprietary pricing engine to turn claims into delivered business insights. We support contract negotiations through scenario modeling capabilities and robust payment collections processes through underpayments analytics and revenue recovery. Let Kubera cook.
Feel free to reach out to me if you’re interested in chatting about claims analytics, Kubera, or cooking horror stories