Next Generation, Advanced Claim Auditing Services generate significant healthcare cost reduction for a Self-Insured employer/Plan Sponsor. Why? Fully-Insured Insurance Company solutions are governed by the ACA, the Medical Loss Ratio Provision which states the Insurance Company has to pay $0.85 of every premium dollar collected toward a healthcare claim. Their gross revenue is capped at 15%. So, the only way the Insurance Company can increase net profit and shareholder dividend is to pay more in claims. To a certain extent, Insurance Companies offering Self-Insured plans have no incentive to reduce healthcare claims payments. When an employer becomes Self-Insured (Level-Funded, Traditional or Captive) all of these dollars are owned by the employer and whatever discounts or savings can be accomplished are retained by the employer.
Hospitals/Providers un-bundle patient claims creating significant charges over and above procedure cost. Additionally, many other items are billed at excessive rates regardless of how much of the item was needed for the patient procedure. Historically, Insurance Companies do not audit claims. Read the case study below. We have many others available on request
- CASE STUDY -
SUMMARY
• Member treated at a hospital facility in central California
• Member was treated for chronic cholecystitis (chronic gallbladder issues common with recurring gall stones)
• Member received surgery which was charged at $15,825.44 (billed charges)
• Hospital facility then unbundled the same charges and billed them separately aka Un-bundled Charges
• Total billed charges: $56,849.64
• Total Amount Plan Saved: $50,944.34
STUDY CONCLUSIONS
These are charges that never should have been included in the bill. We then reduced
the bill even further per its audit process in accordance with the Plan language, saving the Plan a total of
$50,944.34.
