Outpatient Therapy

In managed care, especially Medicaid, outpatient therapy (Physical, Speech, and Occupational Therapy) is susceptible to significant overutilization.

The root cause of the overutilization is a lack of clinical evidence to drive informed UM decisions. When health plans are not armed with actionable data, it is difficult for them to approve the most appropriate Plan of Care. In turn, providers take control of visit frequency and duration. Overutilization ensues.

Reducing fee schedules, shrinking the network, and arduous UM processes only provide a temporary fix.

Through our affiliate Therapy Network, Health Network One uses an alternative payment methodology - a severity-adjusted bundled payment - that shifts the emphasis from visits and units to ensuring the member is properly diagnosed with the most appropriate Plan of Care.

Our commitment to this differentiated and holistic approach delivers tangible economic, operational, and clinical value:

Every new therapy case receives a full clinical review. This approach ensures member severity is properly assessed, which might mean the member is “within normal limits” or needs to be assigned to a different risk category.

Our providers are required to assign a severity level to each case. In turn, our UM team concurs with the provider's assessment over 99% of the time. Less than 1% denials means providers can render care immediately, giving them the best chance of positively impacting the member.

Our networks are constantly growing. Typically we double their size in three years and triple them in five years. Improved access means improved member satisfaction.

Our Case Rate reimbursement is designed to mitigate overutilization but can be abused and create underutilization. Thus, we are hands-on to ensure that any gaps are due to externalities such as member challenges (i.e. transportation) and not because a provider is limiting appointments.

Outpatient Therapy is a high volume, low unit-cost specialty. We are typically delegated UM, Claims, Credentialing, and Network Management. Those administrative costs are embedded in a single capitated payment that also includes all medical costs.

We take on 100% of the medical cost risk. The upshot is a first-year savings of 10-15%. And that savings percentage grows annually.
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Since 2005, we have been building and enhancing once-in-an-industry capabilities. Through our unique provider reimbursement methodology and expert utilization management team, we deliver significant medical cost savings while expanding member access, building provider loyalty and ensuring the highest level of clinical quality.

Outpatient Therapy is experiencing explosive cost growth. Health Network One can manage this unique specialty for your organization

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