Aggressively followed clinical course of the transplant candidate during the hospital stay.

Intervention: After careful review of the clinical information and benefit limitation, noted that patient received non-FDA approved device.  Worked with TPA on the claim review.  In addition, re-negotiated the transplant contract thru a transplant network.

Result: Billed charges-$1,200,000. 

Final paid amount: $450,000. 

Savings: $750,000. 

Due to the continuous routine case follow up, potential large claimants are tracked.  Not only are claims savings  significantly achieved, underwriting also benefits from the accurate risk assessment.

Summary: Despite being told by a TPA’s case manager that no BMT was planned on a patient with Leukemia, project BMT estimate after thorough research.

Intervention: an aggressive cost projection of $1,000,000 was estimated and relayed to the underwriter.  Group renewed.

Result: The patient had a 4 month hospital stay, including a BMT.  Total claim cost-$990,000. 

Savings and benefit: No stop loss claim and $1 million of premium was captured with the renewal.

After careful review of clinical information and plan benefit, alert TPA and case manager of this phase I/II BMT study protocol.

With the employer’s decision on the non-covered experimental service, the patient was informed and presented with alternative treatment plan.

Result: The patient did not pursue the experimental transplant and opted for the conventional chemotherapy.

Savings and benefit: over $200,000 on the BMT and positive feedback from the TPA and broker on the case handling.  The denial burden and decision was presented to the employer/TPA with the treatment information. 

As part of the routine notification screening process, review all network and non-network claims that have questionable billing items.

Billed-$89,000

PPO-20%

Dx: Cardiac Arrest

Bill Summary: patient expired during a 23-hour observation stay.  Result: Provider admitted to billing error of $80,000 on the “MISC” and re-billed.  The new charge was $8,900.

Savings: 70% despite an average PPO discount of 20%.