Savings Levers in Sync

Today more than ever, payers are challenged with generating improved health outcomes while maximizing savings. It’s one of the reasons health plans are increasingly choosing solutions that function across disparate silos, enabling greater coordination of care and a true understanding and mitigation of costs. 

For over 20 years, ProgenyHealth has improved maternal and infant health outcomes while reducing costs by integrating utilization management, case management, and NICU payment validation and assurance. From maternity case management to NICU care management to postpartum support, we enhance outcomes through telephonic and app-based resources, provider collaboration, and member engagement—driving better health outcomes and substantial cost savings. Here’s how we help health plans save money to reinvest in population health programs and more.

The power of an end-to-end solution lies in its comprehensive nature and its inherent ability to drive downstream benefits for members and health plans alike. Even if a major complication is not apparent early in a pregnancy, simple interventions that monitor for rising risk can have a profound impact. For example, ensuring a pregnant member with a history of high blood pressure has the resources to maintain healthy levels throughout their pregnancy may significantly reduce the future risk of preeclampsia. In other cases, a healthy pregnancy might result in an unplanned NICU admission, and ProgenyHealth is there to work with the member and the provider to ensure timely support and evidence-based clinical guidelines. From the moment ProgenyHealth learns of a pregnancy or NICU admission, we are working to enroll that member in our Case Management services and conduct an initial health or needs assessment. Regardless of when a member begins engaging with our services, the common thread in every case is a commitment to managing risk and improving outcomes, while impacting total cost of care.

Maternity Case Management 

Often 85% of a health plan’s total newborn admissions cost comes from newborns needing NICU care. At ProgenyHealth, we first aim to lower the frequency and severity of these cases through our Maternity Case Management program. We’ve learned that timely enrollment, a user-friendly mobile experience, consistent member engagement, and proactive clinical intervention significantly improve maternal and infant health outcomes. 

Our approach leads to:

• Less severe NICU cases
• A decrease in emergency room visits
• A decrease in unnecessary hospital admissions
• Cost-neutral impact—our efforts to reduce NICU cases and manage costs effectively help offset the program’s expenses

We stay closely connected to pregnant women and act as their trusted advocates – identifying risks, solving for needed resources, offering educational and emotional support, and helping with the transition to home and back to work, or providing support if a NICU admission occurs.

NICU Care Management

NICU Utilization Management

Through NICU Utilization Management, ProgenyHealth ensures each NICU admission is warranted, and that each infant receives the appropriate level of care and length of stay, preventing unnecessary NICU admissions. In our experience, there is a wide variation in NICU care across hospitals, driven by factors such as physician practices, geographic location, and resource availability. This variation can lead to disparities in treatment and outcomes. Our program goes beyond traditional Utilization Management while standardizing care to optimize both clinical and financial results.

• We monitor Level of Care by ensuring NICU bed levels, billed under Revenue Codes 172, 173, and 174, accurately reflect an infant’s clinical condition. The most intensive (174) days are costly, so we track improvements to align billing with the infant’s progress toward discharge.
• Length of Stay (LOS) is a key cost driver, with the national NICU average now at 20 days. ProgenyHealth consistently reduces this, with partner health plans seeing average LOS decrease by 10%—allowing families to go home sooner, while driving savings across all payment methodologies.
• We also ensure Accurate Diagnosis Coding, validating that DRGs align with clinical guidelines to control inlier costs. In some markets 112 possible NICU DRG coding combinations make proper classification of diagnosis codes crucial for cost management.

By integrating care management from admission through claims processing, we create personalized care plans and conduct regular assessments to ensure each infant progresses appropriately bridging the gap in NICU care, and that the clinical progression is accurately reflected in the resulting claims. 

NICU Case Management

Should a NICU admission occur, our NICU team supports infants and their families through every milestone. Whether it’s emotional support, health literacy training, or assistance with discharge, ensuring infants are not readmitted is essential for success and a smooth transition home. It’s for this reason we reach out to 100% of members following delivery.

Read more about how our dedicated Case Managers support NICU infants and families to get the right care at the right time and place: 

Thomas, a baby born two months premature who spent two weeks in the NICU. Thomas’s mother, Sarah, was understandably very stressed and scared. ProgenyHealth stepped in to support the family during this challenging time by addressing various SDoH factors. They helped schedule transportation for Sarah’s initial and ongoing doctor’s visits, located short-term housing, provided education materials for breastfeeding, and signed her up for local WIC services. This comprehensive support not only helped Sarah manage her immediate needs but also contributed to preventing Thomas’s readmittance to the NICU by ensuring they had access to necessary resources and support systems.

NICU Payment Validation and Assurance

ProgenyHealth’s payment integrity program ensures health plans maximize NICU financial value by thoroughly reviewing claims and comparing billed charges to clinical data obtained during utilization management. In our experience, 80% of all NICU claims have some degree of inaccuracy, and savings can be identified on 20-30% of reviewed claims. Savings are often found on very routine NICU cases due to coding variances.  That is why we are committed to reviewing 100% of NICU claims.  As a result, our work typically yields savings of $7k-$10k per finding, representing savings of $1k-$3k per member managed by NICU Utilization Management.

Our process identifies savings by reconciling revenue codes with authorized levels of care and length of stay, detecting inconsistencies that may impact billing. We also validate whether assigned diagnoses are properly supported, providing detailed recommendations with explanations and references to reduce appeal rates. Our reconciliation applies to all payment methodologies—including per diem fees, percent of charges, and DRG case rates (including outlier payments). With a contingent fee structure based on savings, PVA delivers cost-effective financial assurance. 

No Stone Unturned

By seamlessly integrating Maternity Case Management, NICU Care Management, and Payment Validation & Assurance, we ensure that every stage of the maternity journey is optimized for better outcomes and financial efficiency. Our proactive approach of identifying risks early, supporting families through NICU stays, and ensuring accurate billing delivers measurable results, including fewer severe NICU cases, shorter lengths of stay, and significant cost savings. Through our comprehensive and compassionate care model, we not only enhance the health of mothers and infants but also empower health plans to reinvest in broader population health initiatives, creating a lasting impact on the communities we serve.