More than $900,000 saved with a Medical Bill Review
EthiCare was referred an inpatient hospital claim of nearly $2,700,000 by an MGU that was handling a stop-loss claim on behalf of a stop-loss carrier. The claim was for a premature infant with numerous severe conditions. The high-dollar claim was processed by the TPA and paid by the Plan with a sizable PPO discount of 45% off of billed charges, creating an allowed amount of “only” $1,500,000. However, the claim was not audited by the administrator to determine if the actual billing and coding of the claim was appropriate. EthiCare performed a Medical Bill Review (“MBR”) Audit on the claim in question and uncovered $934,000 in billing and coding issues. It should be noted that EthiCare’s fee for performing the MBR Audit was only $5,000. In other words, the net savings potential in this case was $929,000.
EthiCare Prior-Authorization service helps plan obtain a 63% discount
A pro-active TPA and Employer Group implemented the EthiCare prior dialysis authorization service as a way to protect the employer group from steep dialysis charges by adding a plan amendment and EthiCare’s prior-authorization phone number to the back of their benefit card. EthiCare Advisors received a prior-authorization call from a large dialysis provider before the group’s patient started dialysis treatment. EthiCare worked with the TPA and the provider to obtain a discount that will translate into savings of more than $500,000 for the year. The all-inclusive settlement along with a signed release from the provider ensures no patient liability above their standard co-insurance and it also protects the group from future price increases.
EthiCare Saves Employer group more than $750,000 in one year on Dialysis Claims
EthiCare Advisors, acting on an out-of-network referral from a pro-active MGU, was able to ink a settlement agreement with an out-of-network dialysis provider. The provider originally wanted the group to utilize a weak wrap network discount they were eligible to access, but EthiCare was able to settle with the provider at a much more reasonable rate. The bottom line, our negotiated settlement saved the group from utilizing the inferior wrap network discount, saving our client an additional $500,000 over 12 months.
A Patient’s Question leads to $180,000 in Savings
A 67-year-old male patient with Hodgkin’s Lymphoma questioned the cost of the radiation therapy he was receiving. As a result, EthiCare Advisors, Inc. was contacted by the TPA to review the claims that charged the plan $75,000 per treatment. Team EthiCare reviewed the case and presented the cost saving options to the client. EthiCare was able to negotiate a 40% discount per treatment, resulting in a $30,000 savings for each treatment the patient would receive. This case has the potential to save our client a minimum of $180,000 this year.
Over $77,000 saved on Surgeon Bills
EthiCare received a claim referral that included two claims. One medical bill was a surgery claim and the other was the corresponding assistant surgery claim, both from a neurosurgery group. Both the surgeon and the assistant surgeon each charged $49,954.32 for their respective services totaling $99,908.64. EthiCare successfully negotiated a comprehensive settlement totaling $22,800, inclusive of provider sign-off ($19,000 for the surgeon’s claim and $3,800 for the assistant surgeon’s claim). We presented our client with total savings of $77,108.64 or 77% of billed charges.
EthiCare Negotiated a 56% discount on a Surgery Center Claim
EthiCare received a $34,500 facility claim from a client. The claim was from an ambulatory surgery center in New Jersey. EthiCare was able to negotiate a settlement on the claim, obtaining a signed agreement that reduced the billed charges to only $15,000. This equated to a discount of over 56% off of the original billed charges, resulting in total savings on the claim of $19,500.
Nearly $85,000 saved on Surgery Center Claims
An EthiCare client asked us to negotiate a settlement on multiple ambulatory surgery center facility claims for a patient receiving numerous vertebral facet joint injections at many different levels (i.e., cervical, thoracic and lumbar vertebral levels). The billed charges for all claims totaled $141,400, for dates of services that spanned over 9 months. EthiCare successfully negotiated a discount of 60% off all billed charges; reducing the collective allowable amount on the claims to only $56,560. EthiCare saved the client $84,840.
U&C Recommendation Saves over $600,000
EthiCare received a hospital claim from a client that totaled $971,033.05. After a detailed U&C evaluation, EthiCare determined the U&C amount for the hospital confinement was $346,367.07, taking into consideration the patient’s diagnoses, procedures rendered during the confinement, length of stay, geographic area where services were rendered and the patient’s age and gender. The U&C amount represents a difference of $624,665.98 from billed charges. Subsequently, the client received several appeals from the provider. EthiCare assisted with all the appeal responses; as a result of the continued assistance, the original decision to apply U&C to the claim was upheld and the savings were maintained.
MGU saved over $200,000 using EthiCare’s U&C Service
One of EthiCare’s MGU clients asked us to review a patient’s nearly 4 month long high-cost drug treatment that totaled $821,673.00. The provider was in-network with a corresponding discount of 48% off of billed charges. The allowable amount was “only” $427,269.96 after the PPO discount was applied. On the surface, that appeared to be a “good deal” for the payer; however, after a thorough review of the claims and the services rendered, EthiCare determined the total U&C amount for the claims was $225,388.10. As a result, the provider received nearly twice the U&C amount for the services rendered in its geographic area when the first-dollar claims were adjudicated by the TPA on behalf of the health benefit plan. EthiCare’s MGU client opted to apply U&C to the claims since the applicable stop-loss policy contained terms and provisions that supported the application of U&C during the claim adjudication process. In the end, our MGU client saved $201,881.86 on the applicable stop-loss claim by utilizing EthiCare’s U&C services.