Financial Impact Calculator
Model the payer savings unlocked when CareFuse prevents low-benefit hip and knee surgeries by redirecting members before authorization.
Average number of hip and knee prior authorization requests your utilization management team processes each month.
Percentage of requests currently approved for surgery before introducing CareFuse decision support.
85%Share of approved members that the CareFuse model flags as unlikely to meet MCID based on their clinical profile. Locked at 30% using CareFuse's validation benchmarks.
30%Total payer spend per surgical episode, including facility, professional, and post-acute costs.
Projected count of TKAs prevented by redirecting low-benefit members to enhanced conservative care pathways.
Estimated reduction in direct medical spend by avoiding surgeries and associated acute and post-acute services.
Combined peer-to-peer and overturn cost reductions from fewer disputed cases and streamlined reviews.
Net financial benefit after accounting for CareFuse licensing and implementation expenses.
Model assumptions
CareFuse surfaces members who are unlikely to achieve clinically meaningful improvement so payers can redirect them to conservative care instead of authorizing a low-benefit procedure.
- Complication risk: 7.8% of arthroplasty episodes experience serious inpatient complications that add $14,800 in incremental spend per event.[24]
- Readmission burden: 4.2% of cases trigger a 30-day readmission with an average $13,400 medical cost.[25]
- Revision exposure: 2.2% of index surgeries require an unplanned revision within the first year at an average cost of $49,360.[26]
The calculator applies your baseline episode cost plus the expected value of these downstream events to every avoided surgery, assumes 75% of low-benefit approvals can be redirected, and keeps the flagged member rate fixed at 30% based on CareFuse model benchmarks.