SCALE Case Study:

Marketing Research – Family
Care Services

Client Profile

  • Size:
    9 Clinics
  • Location:
    Alabama Tennessee
  • Specialty:
    Urgent Care Family Care Services

Services Deployed

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Market Research

Coding Analysis

Overview

SCALE was engaged by an investment banking firm to complete a market assessment and regulatory analysis for the acquisition of multiple rural health clinics in the southeastern US.

  • Investors sought guidance on how rural healthcare demand and innovative reimbursement models could support their value-proposition and acquisition strategy.

Findings

  • Target clinics aim to create a value-based care roadmap to expand quality care access
  • One clinic is eligible for a Rural Health Clinic (RHC) designation to generate additional revenue, while other clinics are well-positioned to provide telehealth and remote patient monitoring (RPM).
  • Expansion strategy includes an increas

Execution

SCALE’s market research team analyzed commercial payer reimbursement trends, and underlying reimbursement policies impacting trends affecting RHCs, telehealth, and RPM. SCALE provided a detailed summary of reimbursement analysis and trends for high volume CPT codes. The team also completed a follow up review of new CMS guidance on care management services.

  • Rate Analysis: Summary of reimbursement through the Medicare Fee Schedule, reimbursement rates across different payers, changes to service reimbursement, volume, and payer mix over time, and new coding updates
  • Telehealth Research: Overview of payment policy as revenue drivers, federal and state regulatory changes throughout the pandemic, state legislation, and federal proposals to increase rural access
  • RHC Designation Review: Summary of enhanced reimbursement, clinic and provider shortage areas, average RHC characteristics, and both reimbursable services and the potential impact on revenue relative to payer mix
  • RPM Coding Guidelines: Creation of a roadmap for the use of RPM in patient care based on existing federal and state policy frameworks and reimbursement models

Results

  • Achieved high client satisfaction based on feedback received regarding the content and knowledge of commercial reimbursement and health policy changes during follow-up discussions
  • Followed up the initial assessment with additional information on developing coding changes, federal Medicare payment legislation, and recent coding changes for evaluation and management services
  • Provided a detailed summary of telehealth state law and insurance regulations to inform potential growth
  • Helped client understand the health policy landscape for rural clinics based on new care delivery models and opportunities for value-based care
  • Outlined value-based care models for federal programs, accountable care organizations, and risk-sharing agreements
  • Helped client understand additional revenue generation from the RHC model and adjustments needed to current business model to optimize value to patients
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