About Surgery Shopper
How it All Began
For years, consumers have paid cash at the time of service for many health services, including:
- Cosmetic surgery
- Surgical and other procedures that were deemed “experimental” or “investigational”
- Patient-paid clinical trials on off-label drug use
- Stem cell injections
- Concierge medicine memberships
- Direct-pay primary care
- Non-covered elective and medically necessary surgical and diagnostic services
- Out-of-area services not covered by their insurance
- Out-of-network providers they trust
- International medical and wellness travel
- Massage therapy and the services of professional athletic trainers and nutrition counselors
- Many alternative and complementary health services, and
- Drug and alcohol and behavioral health services at prestigious clinics
Savvy patients negotiated prices with their healthcare providers in advance, paid on (or before) the date of service there was no revenue cycle expense other than a single transactional exchange. One and done.
Lately, group health purchasers want the privilege to purchase surgery in pre-negotiated, transparently-priced, bundled episodes of care. But they haven’t quite thought through the procurement process. And at the prices they find on our innovative SurgeryShopper.com marketplace website, the privilege to purchase surgery for themselves or their employees and dependents is just that… a privilege. They are ready for a different relationship that’s unlike PPO and HMO alternatives. But to get it, they have to play by new rules.
- One problem they face is knowing where to look and whom to call to get access to these preferred rates. They don’t have time to shop website by website and risk not finding what they were looking for.
- Another is that they don’t have contract form agreements prepared to purchase packaged surgical services, so they adapted their existing managed care agreements to get “something” down on paper. Those contracts are so mismatched with procurement or administration of a pre-negotiated, transparently-priced, bundled episodes of care, that they feel just like wearing the wrong shoes on one’s feet. A total mismatch. Why? Because a transparently-priced, bundled episode of care package s a different “product” than the typical managed care discounted, fee-for-service business model.
- A third problem they face is they don’t really know what price to offer. So they’ve tried reference-based pricing, which doesn’t work. Many are beginning to accept that it is not their place to set the price in this new value-based purchasing model. Instead, in this model, they have the prerogative to accept or reject the providers’ prices, terms, conditions of sale. Those are the new rules.
In the transparently-priced, bundled episodes of care business model, all the typical costs of revenue cycle (billing, waiting, appealing, follow up, risks of ineligibility, risks of non-coverage, the expense of pre-authorization coupled with disclaimers of possible non-payment), suddenly disappear. But only if the contract form agreement eliminates it.
The problem with the adaptation of traditional managed care contract form agreements is that they want the cash pay pricing but they left the revenue cycle expense and performance duties in the contract. The option to pay less than what they have been paying for years involves a different “product“. One that costs less to produce.
Perhaps they didn’t know any better; perhaps they didn’t realize the shoe is on the other foot; and perhaps they didn’t realize that in bundled case rate negotiations, leverage is with the provider to agree to sell the transparently-priced, bundled episode of care package product to their best customers under very different terms and conditions.
How we help our providers bring transparently bundled packages for surgical episodes of care to the marketplace:
We introduce you to experienced, independent consultants who will…
- Support you with pricing and price integrity tools to eliminate the risks of ambiguity and misinterpretation. This eliminates most of the financial risk for providers by nailing down what’s included and excluded in clear and transparent terms, by procedure code.
- Supply the contract draft agreements for use with consumers ready to pay cash at the time of service, in full, and for those who want extended payment terms.
- Supply the contract draft agreements for use with self-insured employers who would like to contract directly without going through PPOs or HMOs (known as “disintermediation”).
- Supply the contract draft agreements for use with non-payer middleman agencies e.g., TPAs and other group health programs such as health sharing ministries and other healthcare purchasing coalitions.
- Supply the contract draft Attachments and Exhibits to align and redefine:
- What constitutes a Clean Claim (single line item billing for a bundled episode of care);
- Your formatted and proprietary price list and the terms and conditions that apply to this Alternate Fee Program for transparent, bundled rate pricing;
- A the list of Authorized Payors you have agreed to work with so you maintain control of who can access your program and your bundled case rates and eliminate Silent PPO problems.
- how you’ll provide delegated credentialing and privileging to help Plan Administrators to meet plan fiduciary requirements and accelerate patient access.
They’ve agreed to discount their consulting fees and bundle the document set above exclusively for our participating providers.
We support your medical travel programs as well
Domestic (and international) medical travel has been happening for decades. Our founders began coordinating travel to healthcare centers of excellence in the 1970s. But it wasn’t associated with a specific term to describe it. Hence, in most instances, the general public just “did it”. They simply made an appointment and traveled to the destination where the provider was located. If they needed overnight accommodation, they arranged it. The media didn’t talk about it or create any buzz. Now, that’s changed.
Medical tourism gives the media content to talk about on TV, on talk radio, in blogs, in newspapers and consumer magazines. and trade journals. Conference organizers have banked millions of dollars from stand rentals, dubious overnight success certifications and certificates, and unrecognized, dubious copycat accreditations. Travel agents have expanded beyond their training and experience to coordinate medical trips that place patients at risk for altitude physiology mishaps and hotels that are inappropriate for peri-operative patients.
In about 2003, the phrase “medical tourism” started to gain popularity with individual consumers but usually only mentioned in the context of leaving the USA. In fact, more than 90% of websites and stories by the media about medical tourism wrongfully describe it as traveling to another country to access healthcare services. This inaccurate definition leads the general public to overlook the option of domestic medical travel. Both “domestic” medical travel and “cash pay surgery” have been a marketplace secret for too long.
Unfortunately for all concerned, most hospitals and ASCs lack the marketing strategy and the contracting tools to let the world know about the options they offer that don’t require patients to leave the USA and take their cash to another country. We’ve solved that problem.
Surgery Shoppers.com provides the online shopping site that promotes full pricing transparency, fairness, support for cash pay bundled prices, and direct to consumer options and direct to employer coordination of care continuity, patient movement, and outcomes measurement.