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Dec. 21st, 2016 - Amir Inbar, CEO - Mediclever Reimbursement Consultants Ltd.© Copyright 2016 Mediclever Ltd. All rights reserved. Proprietary and confidential. Neither this presentation nor any information it contains may be viewed, disclosed, published, reproduced or used for any purpose without prior written approval from Mediclever.

Payers, Providers & the

Business of Healthcare

About Services Resources

Navigate your reimbursement pathway smarter.


2. Healthcare Markets1. Introduction

2.2. Operation2.1. Formation


How I Ended up Here?

North America

Europe

Other

Amir Inbar

Founder and CEO

Arie Shen

US Business

Development and Sales

Gerald N. Rogan, MD

Senior Reimbursement

Consultant, USA

Peter Buschmann


Consultant, EU

Prof. Dr. iur. Gerhard Igl


Consultant, EU

Richard K. Baer, M.D.


Consultant, USA

Neil Grubert

Pharmaceutical Market

Access Specialist

Anat Elhai

Director of Operations

Carlos Del Giudice

Market Access

Specialist, Spain

Malca Chen-Zion, Ph.D.

Clinical and Regulatory

Consultant

Dr. med. Ferdinand

Hundt

FFPM (RCP UK)

Ernesto Gallone Arnaboldi

Market Access Specialist,

Italy

Majed Elhewaihi, PhD

Market Access

Specialist, EU

Yehuda Zicherman D.Sc.

Market Access Specialist

Gianluca Furneri

Market Access, Pricing &

Health Economics

David Furst

Advisor



http://www.google.com/url?sa=i&source=images&cd=&cad=rja&docid=LOLpkfyznxun2M&tbnid=Mwr5xumbdVNXBM:&ved=0CAgQjRwwAA&url=http://www.123rf.com/photo_15447393_canada-flag.html&ei=vv-qUYCHEsbVPNiPgZgE&psig=AFQjCNE8nj06B-K6u3BJyoTPd26OH2BTTw&ust=1370247486332230

http://www.google.com/url?sa=i&source=images&cd=&cad=rja&docid=LOLpkfyznxun2M&tbnid=Mwr5xumbdVNXBM:&ved=0CAgQjRwwAA&url=http://www.123rf.com/photo_15447393_canada-flag.html&ei=vv-qUYCHEsbVPNiPgZgE&psig=AFQjCNE8nj06B-K6u3BJyoTPd26OH2BTTw&ust=1370247486332230


JohnDr. Zhivago

1848

Charlottesville




= ~$1,200

Physicians practicing in Charlottesville, Medical Charges, June 9th, 1848 (http://blog.hsl.virginia.edu/feebill/)

Charlottesville

1848

JohnDr. Zhivago




$40 (Amputation

rate)

JohnDr. Zhivago




Employees

$40 (Amputation

rate)

$35 (Amputation

allowable rate)

JohnDr. Zhivago




Employees

$35 (Amputation

allowable rate)

Dr. Zhivago




Charlottesville

# in group:

Probability of amputation, per person, per year:

Cost per amputee:

Expected monetary value for group:

100

2%

$35

$70

~$30 (Administration

and Profit)

$1

(Premiums)

~$70

(Payment)

Employees

$35 (Amputation

allowable rate)

Employees & Employers

Dr. Zhivago




# in group:

Probability of amputation, per person, per year:

Cost per amputee:

Expected monetary value for group:

100

2%

$35

$70

Dr. Zhivago


$1

(Premiums)Premiums

~$70

(Payment)

~$30(Administration

and Profit)

~30%

Healthcare Providers




Premiums

~30% (Administration

and Profit)

Health Insurer






Young invincibles

Pre-existing conditions

Unemployed

Uninsured

(Administration and Profit)

~30%Max: 15%

Premiums

Health Insurer






Young invincibles

Pre-existing conditions

Unemployed

Uninsured

(Administration and Profit)

Max: 15%

Premiums

Health Insurer





Citizens

PremiumsTaxes

NHS(National Health

Service)

Health Insurer




NHS(National Health

Service)

Health Insurer



Premiums


Citizens

Taxes

Beneficiaries

Payers





Beneficiaries

Payers

Treatment





Beneficiaries

Payers

Treatment

Out of Pocket

39%

32%

12%

17%

USA

Reimbursement (71%)





Beneficiaries

Payers

Treatment

Out of Pocket

39%

32%

12%

17%

USA

Reimbursement (71%)

Healthcare Providers (HcP) Beneficiaries

Treatment

Payers





Treatment

Payers

What is Reimbursement

• When Payers pay Healthcare Providers the agreed upon allowable rate,

• for treating their beneficiaries

• according to their coveragecriteria.





Treatment

Payers

Without reimbursement very difficult to reach mass volumes.

Why Reimbursement





Treatment

Payers

a. The problem Diagnosis Code/s

b. The service Procedure Code/s

c. Add. details Age, gender, etc.

2. The Payer checks if the above combination has COVERAGE

1. On his claim, the HcP uses CODES to tell the Payer:

10101101

3. If positive, the Payer pays the healthcare provider according to the allowable rates

$

Reimbursement =101110

$10101101 $+ +



How does it work



$10101101 $+ +




Treatment

Payers



$10101101 $+ +

1. Reimbursement is comprised of Codes, Coverage and Payment.

3. Different settings Different reimbursement mechanisms.

2. To obtain reimbursement, different stakeholders should be convinced to allocate codes, grant coverage and assign payment rates.





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