Carriers & MGUs: Did you know EthiCare Advisors provides these services too?

As a provider of medical stop-loss insurance, you may have heard about EthiCare Advisors’ claims settlement services. While many consider our claims settlement services second to none, we also want to remind you of other services we provide for stop-loss insurance carriers and managing general underwriters (MGUs) including:

Risk assessment underwriting reviews:

EthiCare’s proprietary knowledge base can serve as a second set of eyes during the underwriting process to help determine the projected cost of a particular risk for the upcoming benefit period. This service can be provided on one particular patient or as a review of the entire group. When a high-costs risk is identified, our claims settlement team can act upon your request to contract with a provider and provide certainty of ongoing cost, giving you an advantage over your competition.

Specific/Aggregate claim file audit:

Our claim file audit team is lead by a former claims manager of a third-party administrator (TPA). We can assist your team with any claims file overflow or for run-out of a particular program.

Implementation calls:

When you sell a new group, do you have a call with your underwriter, your claims manager, the third-party administrator (TPA) and broker to make sure the TPA knows about your expectations for cost containment as well as the resources you can provide them? If you’re not, you should consider it. If you are, EthiCare Advisors can make it better. Participated in literally hundreds of these calls, we can share our deep knowledge of the cost containment options. We have participated in literally hundreds of implementation calls and can share our deep knowledge of various cost containment options.

50% notice analysis:

These notices can provide a lot of advanced warning and how they are handled may make a difference in your loss ratio. Let EthiCare Advisors serve as your partner in culling the relevant information and taking action.

Special projects:

From “the TPA really messed up paying this claim and we need help” to “can you come and talk about dialysis at our next producers conference” and anything in between.

For more information, please contact Mark Hartmann at (888) 838-4422 extension 703.

Additional Discounts on In-Network PPO Claims & NEVER a Discount Pushback


DISCOUNT PUSHBACK. No claims manager wants to hear that phrase.

Discount pushback occurs when the facility that received payment does not allow a discount to stand. This occurs for a variety of reasons including payments being made after the date allowed in the PPO contract or when a cost containment vendor “discounted” a claim through a blind or silent PPO network.

Most MGUs have dealt with discount pushback and, depending on the size of the claim and relationship with the client, it may have been an ugly situation. How do you avoid discount pushback?

EthiCare Advisors’ expert team settles both in- and out-of network claims through direct contracting and obtains a signed release from the provider with every successful settlement. We supply these signed releases to our clients for their files giving them the peace of mind in knowing ALL the terms of the settlement and that there will not be any discount pushback.

We have settled thousands of claims and never had a settled discount rescinded. NEVER.

Our in-network claims settlement service is designed to enhance existing PPO discounts on claims over $75,000. MGUs and Carrier have a unique opportunity to reduce claim costs when they receive a 50% notice or a request for advance funding.

Here’s an example: During a 3 week period we saved one MGU over $175,000 (above the PPO discounts) on advance funding claims for multiple claimants. That’s $175,000 in monies this MGU would have otherwise paid had they not used EthiCare Advisors.

EthiCare Advisors is most successful with in-network claims over $75,000 in billed charges with a PPO discount under 20%. Within these parameters, EthiCare is able to save our clients on average an additional 15% off billed charges on about half of all claims submitted!

The fees for our in-network settlement services are among the lowest in the industry at 20% of actual, realized savings above any PPO discounts. Our savings are like free money to you. They improve your loss ratio and the loss ratio of your clients.

You have the chance to reduce your in-network claim costs, so why wouldn’t you?

Call EthiCare Advisors at (888) 838-4422 when you are ready to reduce your costs.

Combat Hospital Rate Hikes with EthiCare Advisors

We’ve all seen dramatic increases in hospital charge masters lately. Recently, we have noticed some raising their rates two and three times this year. Hospitals say hikes offset increased costs, but it seems many are raising rates to bolster profits or to offset the larger discounts they are giving to Blue Cross, Aetna, Cigna, etc. Don’t you wish you could raise your rates three times in one calendar year?

Patients choose hospitals based on enhanced benefits offered at network providers. Employers let TPAs make network choices on a host of factors, but largely it is based on network coverage and discounts – “deep discounts” they allege as renewal time approaches. But what really is a deep discount?

If a PPO discount at a hospital was 20% in January and the hospital hiked its already sky high rates 10% in April and then another 5% in September, what is your real savings? What is the real value – if any – of that PPO discount? Wouldn’t it be better to have that hospital outside the network?

At an industry conference, attendees were asked what is the biggest threat to self-funding. Overwhelmingly, attendees named networks as the weakest link in the self-funding equation.

EthiCare Advisors is here to repair that weak link. We specialize in securing additional discounts on high dollar in-network claims.

EthiCare Advisors IMPROVES YOUR LOSS RATIOS by reducing claims liabilities. We take in-network claims (exceeding $50,000) and settle them with discounts greater than the contracted PPO discount. Frequently, we turn 10% discounts in 15%, 20%, 25% or more. We offer:

  • SIGNED RELEASE: A signed release from the provider stipulating the settlement terms.
  • NO “BLIND” NETWORKS: Direct settlement means we work with the providers directly to obtain a signed release.
  • LOWEST FEES: We charge only 20% of savings realized by EthiCare Advisors (ie. Less the PPO savings)

How do we do it?

Our settlement process starts with a mini-audit of the claim to review all charges. We often uncover billing issues including coding errors, duplicate charges, incorrect charges, and bundling issues. These errors are used as the basis of leverage when we speak directly to the patient accounts manager at the provider. We discuss the situation and resolve the questions through a signed agreement with the provider that stipulates the payment terms and conditions.


43.8% of the time on in-network claims we can increase a PPO discount.

Here are some recent examples of savings:

2014-05-16 17_25_38-» Blog Archive Combat Hospital Rate Hikes with EthiCare Advisors »

Working with us is fast, simple and costs less!


We settle most claims within 1-5 business days with special attention to those marked priority.


Just complete a claims submission form with as much information as you have and fax or email it to us.


Only 20% of the savings we generate. We only get paid if we save you money!


Worthless items sold over and over…

The deed to the Brooklyn Bridge.

Late night infomercial diet pills.

Plots of land on the moon.

Paltry 15% PPO discounts from the big 2 dialysis providers.

At least with the first three on the list, you only lose the amount of money that you paid. When you “buy” a bad PPO discount, the ongoing negative consequences could easily cost $1 million over the course of treatment for a patient. If the deal seems to good to be true, it usually is.

Looking for a Specialist?

When it comes to assisting payers on saving claims dollars, don’t you think a specialist in a particular field is helpful?

Fortunately, EthiCare Advisors makes it easy because we have the specialized claims settlement services to make your job easier. We offer:

Dialysis Settlements
Medical Bill Reviews/Audits
Proprietary inpatient UCR database constructed from 20+ years of self-reported provider data
Negotiated settlements complete with a signed release
Risk assessment/financial prognosis underwriting reviews
Many other specialized projects

EthiCare Advisors team of specialists in their field provides many settlement options for your claims. If you are looking for one company that can provide real results at a great price while remembering customer service builds relationships – look no further than EthiCare Advisors.

For more information, please contact Mark Hartmann at (888) 838-4422 extension 703 or simply complete our send us an email form online.

Elements of Medical Bill Auditing

A review of the EthiCare Advisors’ audit

An audit is the evaluation of an organization, system, process or product performed by a competent, independent, objective, unbiased person or persons known as auditors. The purpose of an audit is to make an independent assessment based on the representations of another. In the world of medical claims, auditors using industry standards make independent assessments about bills presented by healthcare providers for payment.

EthiCare Advisors’ audits focus on uncovering potential: coding errors; duplicate charges; provider upcoding; unbundling; coding incompatible with reported diagnosis; and medical necessity issues. We accomplish this utilizing a proprietary, state-of-the-art auditing system run by a team of experienced expert auditors.

The American Medical Association’s CPT® and CMS’ HCPCS codes combined with the widely accepted billing guidelines used for federally mandated programs serve as the foundation of the EthiCare audit. Building upon this foundation, our auditors compare billed charges against the National Correct Coding Initiative (NCCI) and other industry-accepted guidelines. Lastly, our own algorithms – derived from our experiences and audit data of thousands of claims – is applied to the claim. Our objective is to base our audit recommendations on authoritative sources to ensure that we are both correct in making such recommendations and that any such denials would be accepted by healthcare providers.

WARNING! Beware of Discount Envy

An outbreak of DISCOUNT ENVY has been detected at numerous managing general underwriters (MGUs) and stop-loss insurance carriers across the country. ARE YOU INFECTED?

DISCOUNT ENVY can occur when underwriting a piece of business. A feeling of grief overwhelms you when you realize you can’t be competitive because the PPO discounts just aren’t deep enough to compete with the fully-insured quotes.

The claims department also experiences DISCOUNT ENVY when they see a $300,000 with a 3% discount when they know the same provider gave a 40% discount on a $10,000 claim.

Listed are a few of the symptoms of DISCOUNT ENVY:

  • The underwriting department using last nights lottery numbers to help determine rates;
  • Extra large bottles of antacids on the claims manager’s desk;
  • Marketing developing a 2 for 1 campaign – Buy a family, get a single for free;
  • Discounts being rescinded;
  • 20 minute tirades on how a hospital can charge $15,000 per night for a room and $10 for an aspirin, then offer a 20% discount and expect you to be happy.

In order to treat the symptoms and help cure DISCOUNT ENVY – we suggest utilizing EthiCare Advisors daily.

You don’t need a prescription for your daily dosage of EthiCare Advisor’s in-network claims settlement services. Save an average of 15% ABOVE THE PPO DISCOUNT daily with EthiCare Advisors to relieve DISCOUNT ENVY. Nor do you need a Doctor’s referral for EthiCare Advisors’ low fees of 15% of savings which come complete with a signed release on out-of-network settlements.

A website has been established for more information about this troubling condition,

Please don’t let DISCOUNT ENVY spread!


How’s Business Going?

Now that the relative calm of summer is over, the January push is starting up for most stop-loss managing general underwriters (MGUs) and insurance carriers. How would you assess your year so far? Are you writing the business you want to write or do you feel like every renewal is a fight? What about new business? Are you competitive or are the insurance brokers and third-party administrators (TPAs) not even giving you a second look?

How about claims? Is the loss ratio where you forecasted or are the claims chipping away at your profits?

As a company that interacts with many managing general underwriters and insurance carriers from large to small, we are hearing of many entities fighting hard to keep good business while seeing very little opportunity to write new cases. The wildcard in the process are the claims and how they are administered.

It is no secret that some administrators work better with some managing general underwriters and insurance carriers than others. It is also understood that many managing general underwriters & insurance carriers have strong opinions on how a specific third-party administrator operates.

As you evaluate your current position for the year and develop your year end plan, we at EthiCare Advisors remind you that while proper underwriting is very important, do not forget to assess your claim operations. Perhaps the following discussion points will get your company talking.

1. What is the maximum percentage of savings fee you allow to be reimbursed? Do you allow third-party administrators to charge for claims settlement services or do you consider it part of their fee? Do you allow third party firms to “buy” the claims from the providers and resell them to the plan? If not, what do you do when the situation arises?

2. Do you have someone either internally or externally that reviews large claims (over $50,000) regardless of the discount? Do you always request an itemized bill for large in-patient claims? If so, what do you do with them? If not, why not? Will you pay for duplicate charges? How about implants that were never used? Should the provider/hospital and/or network be able to dictate payment terms or should the plan document dictate payment terms?

3. How have dialysis costs affected your business over the past 5 years? Do you stay away from writing cases with a dialysis patient? If you had a better handle on dialysis costs could you write more business? Are you willing to pay dialysis providers up to 4 times more than you have to because they are in-network?

4. Does your organization pay claims according to the plan document? What about applying Usual & Customary as called for in most plan documents, even if the third-party administrator did not apply it? When you think of health insurance, do you believe it should cover everything or should the patient share some of the risk?

5. Seemingly everyone complains about the costs of certain drugs or implants. What do you do to protect your loss ratio from these charges?

We hope you take a few moments to consider these questions and how your organization deals with each situation. If you find yourself questioning your internal procedures and wanting to discuss potential changes, we are here to help. The proper changes could positively alter your results in terms of sales and claims.

The less you spend – The more you save.

EthiCare Advisors – your Medical Claims Settlement Specialists.

Price – Service – Results


PRICE. SERVICE. RESULTS. These are the three key ingredients in building a successful business no matter what the industry.

EthiCare Advisors, Inc. was founded in 2002 with the goal of reducing the industry average costs of claim settlements from 25% down to 15% of savings. We also decided to include provider sign-offs eliminating discount pushbacks experienced by other cost containment vendors utilizing blind networks. Lastly, and most importantly, we make a customer service commitment to our clients by doing the little things like returning calls, answering questions honestly, hiring employees with a TPA and/or MGU background and providing cell phone numbers of the owners to all of our clients. Nine years later, EthiCare Advisors has a client base which includes more than half the MGUs and stop-loss insurance carriers in the medical stop-loss market, numerous third-party administrators, some fully-insured first dollar carriers, some labor unions, and even some utilization review and case management vendors.

As a leader and innovator in the cost containment marketplace, EthiCare Advisors offers access to in-patient hospital usual and customary pricing data that will comply with the plan document language for many self-funded healthcare plans as well as fully insured policies. Our unique database is derived from the largest, all-payer inpatient care database in the United States. It contains data from approximately 8 million hospital stays from roughly 1,000 hospitals since 1988. We know that this database is the most defensible in-patient facility pricing database available to payors because it is based on actual charge data as submitted by providers nationwide to federal and state agencies collected during the past more than 20 years.

In the words of one of our MGU clients after hearing our pricing structure, “That is bad news for everyone else.” Our philosophy is simple – Cost containment is about saving money for the payor and the best way to do this is with great results at low prices. We charge the same low prices to everyone – from the largest stop loss carrier to the mid-size TPA to the small self-funded plan sponsor, everyone pays the same rate. We would never think of charging 35% of savings like some of our competitors. It is just a wacky idea.

Our customers are the ultimate payers of medical claims and we rely on them for business. We do not obtain business by buying it or offering huge cash incentives. If you are reading this, chances are your organization is a payer of medical claims. If our business philosophies sound appealing to you, please contact us. We are continuously looking for ways to improve the self-funded marketplace and sharing your ideas and opinions are important in improving our industry.

Good Customer Service

Stop-loss insurance carriers and managing general underwriters (MGUs) are in a peculiar position in reducing claims costs. They can’t direct first dollar payment, but if they don’t help third-party administrators (TPAs) watch costs their loss ratios mount causing rates to rise. Most stop-loss insurance carriers and MGUs have found cost containment companies to refer claims to, however few have found companies they are willing to call their partners.

Choosing a cost containment partner is no easy task, especially when your partners regularly interact with your clients. This interaction is a risky proposition. When selecting partners stop-loss insurance carriers and MGUs should seek out those offering the right mix of services, workers with key technical competence and – most important – likable leaders with great people skills.

“Underwriting brings in the business, claims keeps it,” an old insurance adage reminds us. Claims departments must deliver superior customer service while at the same time walking the fine line between paying all the claims, which drive up the loss ratios, or denying all the claims, which scares all the clients away. Claims managers must strike a balance knowing when to pay and when to deny without being pennywise and pound foolish, always keeping in mind the customer and serving their policy.

Everyone wants superior customer service. Everyone promises superior customer service. Few actually deliver it successfully let alone repeatedly. That’s because customer service is very subjective. It is measured in the eyes and hearts of people and every person sees and feels differently about a given set of circumstances.

EthiCare Advisors, Inc. is committed to delivering superior customer service every day through high-touch, customized claims settlement. Every claim is handled, checked or reviewed by an owner. We deliver a level of customer service you simply cannot get by repricing a claim online or through EDI. Here are some of the ways we deliver superior customer service:

Customized sign-off letters for your organization. Each company is different with different needs and requirements. EthiCare Advisors works with your claims staff to develop customized provider signed releases to suit your needs. We can add specific terms and conditions, your unique claim or client number, or specialty compliance language.

Our ability to say no. Time is money. When we know we can’t help secure a discount, we let you know upfront. We do not to waste anyone’s time or resources. Our clients give us considerable respect for just saying “no.”

Our high level of contact. It is not uncommon for clients to call or email us six or more times in one day. They ask questions, inquire about discount relationships, make special requests, etc. We are always accessible. Every client has the cellular phone numbers for EthiCare Advisors’ owners, Mark and John.

Professionalism. When a carrier/MGU refers a claim to us, they are usually referring us to the TPA. We stress the significance that the TPA is the client of the MGU/Carrier and our demeanor reflects back to the MGU/Carrier. We treat your clients with respect and courtesy as you would expect to be treated.

Our commitment to customer service extends to our pledge to charge among the lowest fees in the industry. We only charge 15% of savings for out-of-network claims settlement – compared to the industry standard we are 40% less!

We NEVER access a blind network or silent PPO. Securing a signed release means we NEVER had a discount pushback on our settlements. This gives stop-loss insurance carriers and MGUs the piece of mind in knowing that when a claim is settled by EthiCare Advisors it is settled for good.

EthiCare Advisors offers you superior customer service through quality, customized options at low prices on the terms and conditions you want. Give us a try today. We promise you won’t be sorry.