Flexible Benefits Result in Out-of-Network Claims
With healthcare evolving to empower consumers with more choices, along with interest in taking additional control of their health, employers are being influenced to offer less restrictive healthcare packages. Most healthcare plans allow members the flexibility to use providers of their choice. Due to this flexibility or to circumstances beyond members’ control, there are times when high dollar claims are out-of-network. Claims paid at retail or at Reasonable and Customary result in greater plan cost for both the employer and the member.
In-house Medical Review Negotiation Team
Since 1994, our in-house medical review negotiation team has demonstrated an effective solution for controlling non-network plan costs while maximizing savings, regardless of the chosen provider. Low dollar non-network claims are systematically discounted by means of a second-tier network. Large dollar non-network claims are electronically directed to our skilled and experienced team for efficient and effective direct negotiating, providing a total cost management solution.
The negotiation process incorporates a comprehensive line-by-line review of the charges, along with skilled medical negotiators reviewing the appropriateness of services rendered. The team then aggressively negotiates with non-network hospitals, physicians and ancillary healthcare providers to help reduce our clients’ and their employees’ healthcare expenses. These negotiations encompass a Reasonable and Customary review of the charge levels, as well as a review of the appropriateness of services rendered. Our medical review negotiation team is supported in the negotiation process by a variety of cost databases, claims utilization history databases and reference tools to substantiate their negotiations. Resources available to the medical review negotiation team include:
Database with 30,000+ episodes of care (inpatient, outpatient, etc.)
Medicare fee schedules for physician and ancillary charges
Prevailing charge data for procedures, medical equipment, drugs and supplies
Hospital supply catalogs with wholesale prices
The Redbook for pharmaceutical wholesale prices
Second tier network access