January 23, 2017
By Silver Krieger
New York, NY – MedReview, Inc., a subsidiary of the not-for-profit New York County Services Review Organization (NYCHSRO), which performs Medicare and Medicaid review, offers utilization management and analysis services to the private sector, including labor organizations, corporations, insurance companies, and managed care organizations.
Formed in 1984, it has saved millions of dollars for its clients by monitoring medical billing. LaborPress sat down with Spencer Young, Senior Vice President of Operations and Client Development at NYCHSRO/MedReview since October of 2016, to learn more about him and the services his company provides.
“I’ve been in health care for twelve years, and have a background in risk management. I started in the banking and finance industry out of college,” says Young. “I studied finance, then got a Master’s in Accounting and Finance at American University in Washington, D.C., and switched to health care. There are strong similiarities – both deal with risk. The principles are the same – you just have to learn the terminology and the jargon. With risk, you try to determine the level or risk a situation poses – does it go above and beyond the level of risk you are willing to accept. I worked at United Health Care, in the Risk Management department, and learned all about the company. It gave me a good overview of how the company works and the different issues involved.”
Young then moved on to running the Maryland Medicaid Health Plan, and had an experience that affected him deeply. “We had about 200,000 insured by us. It was eye-opening. You never really understand the problems that people have accessing health care until you’re faced with many examples of problems. A defining moment for me was when we had a young boy, six or seven years old, who had a cavity. No dentist would see him because he had Medicaid. His mother would take him from dentist to dentist but no one would accept this insurance. He went untreated, and it resulted in his death. That was very difficult to deal with. Who would imagine that a child would die of a cavity? The disparities in how people receive and have access to health care made me passionate about wanting to insure people had access to health care.”
While at United Health Care, Young was a client of MedReview, who he says delivered results far superior to other vendors. “I looked at the different vendors we used in different health plans and looked at the results. The results were so good we moved MedReview into other plans, and spread it out to other states. We made MedReview the sole vendor in the Medicaid Health Plan. They knew what they were doing. Also, there was great communication. We’d get calls from them every other week. The head of the company, Joseph Stamm, would tell me where he thought we should tighten policies, and give feedback and advice. And when we needed something or had a question all we had to do was call. Their staff was also very stable – there was a lot of longevity – people who had been there for decades, and that aided in forming relationships.”
The bread and butter of MedReview is the DRG, or Diagnosis Related Groupings, Review. This is a program that reviews hospital coding and billing practices. “The DRG Review works like this,” says Young. “Someone gets sick and goes to the hospital, gets treated for the illness. The doctor writes the chart, and the patient is discharged. The chart goes to the billing office, where they read the notes and diagnosis and complete the claim, which then goes to the insurance company for payment. The bill comes in, and MedReview gets the claim file. We run algorithms, and look at the claims and the medical record. Then we ask, was the medical record coded, and thus billed, correctly, and mark any errors. A specific example, and one we’ve seen a lot of, might be the diagnosis, and thus billing for ‘acute renal failure.’ When we review it, there may be similarities between the two, but, based on the evidence of the symptoms and treatment, it may turn out that it was simply a case of dehydration. What has happened is what we call ‘upcoding,’ where a less expensive illness is coded as one that costs a lot more money. This can be fraud, or it can be a simple human error. In the latter, something like a misplaced decimal point in a baby’s birthweight can cause a normal birth to be coded as a premature birth, which is thousands more.” On average, the review saves about $3500 to $5000 per claim, which results in savings of tens of millions of dollars. “Our largest client in 2016 saved about $63 million,” says Young.
MedReview is now getting ready to roll out new software that will narrow down the claims to look at. “SAS (Statistical Analysis Software) uses algorithms that predict which claims are questionable. This analysis looks at all the claims from the past and decisions that were made to help do this. By looking at less claims, we’ll get better results,” says Young.
The company is expanding, and will be in all fifty states this year, adding 11 million new people. But with growth also comes risk. The challenge, says Young, is to maintain the excellent reputation of the company. “We want to make sure we roll it out properly,” he says. “We have a reputation of doing a very good job, and we want to ensure that remains that same.”